Mind the (cultural competency) gap: bridging cultural barriers in physiotherapy practice - a quality improvement project.

Using the Model for Improvement and Plan-Do-Study-Act to effect SMART change and advance quality.

AimsIt is estimated that 19 million children worldwide are visually impaired and 80% of this is preventable. Therefore, it is vital to ensure that satisfactory eye assessments are performed in...

Use of DECAF scoring system to facilitate early discharge in acute exacerbation of COPD patients: a quality improvement project at a district general hospital

Background: Delivering excellent clinical care in a pediatric cardiac intensive care unit (PCICU) involves coordination of a multidisciplinary team and consistent implementation of best practices. A rounding checklist (RC) may mitigate failures in communication and reduce practice variability. Multiple barriers to successful RC utilization remain, including poor provider compliance. Aim: The primary aim of this quality improvement (QI) project is to implement and evaluate the utilization and effectiveness of an electronic health record (EHR)-based RC in the PCICU. Methods: In collaboration with key stakeholders, we used Plan-Do-Study-Act (PDSA) QI methodology to adapt our existing paper-based RC into an EHR-embedded tool (Fig 1). We conducted educational sessions prior to implementation of the RC to review its potential benefits. We evaluated project impact through pre- and post-implementation surveys of PCICU attendings, fellows and advanced practice providers. Our primary outcome metric was RC utilization. Results: Most pre-implementation survey respondents (n=33), agreed or strongly agreed that they would be interested in using a RC (78%), and it would be helpful (87%). During the first PDSA cycle, of 65 eligible patients, 74% (n=48) had the checklist completed at least once during their CVICU admission. Of 28 eligible providers during the same PDSA, 71% (n=20) completed a RC in the EHR at least once. Most survey respondents (n=25) after the first PDSA agreed or strongly agreed that using the RC is helpful (64%), easy (60%) and can be improved (60%). We continue to modify evaluate the RC and its utilization in subsequent PDSA cycles. Conclusion: Transitioning a RC from paper to the EHR is feasible and improves tracking of utilization. Engaging providers for feedback and making real-time modifications may improve future RC compliance. Continued data collection will improve our understanding of the RC’s impact on health care delivery and patient safety.

Introduction Parenteral nutrition (PN) cost ∼£80 per day to provide. Wastage of PN is high due to sudden changes in the clinical condition of the patient, loss of venous access or for organisational reasons. In healthcare settings improvement in patient quality of care at low cost yet that also achieves savings in provision of patient care is imperative to increase the quality of care available to other patients. We undertook a quality improvement project to reduce PN wastage by 10% in 9 months. Method Quality Improvement (QI) project was carried out at a national Intestinal Failure Unit (IFU) to reduce waste in provision of in-patient PN. Using QI methodology we developed a SMART objective of reducing PN wastage by 10% in 9months. We drew up an appropriate driver diagram of primary and secondary drivers for PN wastage. We recorded reason for wastage and using a pareto chart determined the most likely cause of waste to target change. Using Plan, Do, Study, Act (PDSA) cycles we activated a number of different strategies to reduce wastage. We mapped changes in the main 7 categories for waste using i-charts and g-charts. Balancing charts were also used to ensure that any intervention did not have a negative impact on quality provision of care on the IFU. We compared waste between IFU to Nutrition Support Teams in Salford and in Oxford. Results Baseline wastage over 12 weeks suggested 1000 bags per annum (p.a.) wastage. Using the following PDSA cycles we achieved a 39% reduction in PN wastage in 9 months, exceeding the proposed 10% and saving the unit ∼£35000. PDSA cycles used: Team awareness, regular highlighting of the problem, introducing it as a handover question, relabelling bags if not used whilst still within expiry date, stock rotation of stock bags, following a bag from fridge to patient, better coordination of discharge planning to prevent patients being at home when feed bags still available for them, splitting the fridge storage into days of the week so bags could be placed in correct day for each patient and if bags relabelled moved to the next available day, changing to standard bags during weaning process, taking patients off pre-ordering and changed to daily ordering to allow for altered discharge dates. Conclusion PN wastage is common and costly – in a high use unit ∼£90000 p.a. Using appropriate driver diagram, concurrent PDSA cycles and a motivated team high levels of cost savings are possible with resulting quality improvement in patient care. Disclosure of interest None Declared.

Aims: This Quality Improvement (QI) Project aimed to enhance the overall level of care received/experienced by patients within the Havering Older Adult Mental Health Team (HOAMHT) through combining the clinical expertise of a Consultant Psychiatrist with the pharmacological acumen of a Specialist Mental Health Pharmacist, within a joint mental health outpatient clinic. Key areas tackled included: medication adherence, faster optimization of psychotropic medications, management of polypharmacy, de-prescription of drugs of dependence, physical health monitoring, and expediting patient discharge from HOAMHT back to the GP.Methods: Our QI project utilised Plan/Do/Study/Act (PDSA) cycles. The first PDSA cycle took place in 2023/2024 over 6 months. The second PDSA cycle took place in 2024/2025 over 6 months. The 1st PDSA Cycle used patient satisfaction outcome scoring, which was randomly collected from 15 patients that had been reviewed within the joint clinics. The results from the 1st PDSA cycle led to a second PDSA Cycle being undertaken, in which the establishment of a ten minute pharmacist’s corner feature was implemented within the joint clinic, and further patient satisfaction data was collected. Based on this data, in 2025/26 a third PDSA cycle will take place over 6 months, where there will be joint clinics consisting of junior doctors and pharmacists. This will serve to develop and refine teaching opportunities for the specialist clinical pharmacists. Then, the 4th PDSA cycle will look to expand and include other community mental health teams within our Trust, in order to see if improvements are possible to be achieved at scale.Results: PDSA Cycle 1: There was a 38% improvement in patient satisfaction scoring for joint clinics vs stand-alone consultant/junior doctor clinics.PDSA Cycle 2: Patient satisfaction scores increased further with the introduction of stratification, where the pharmacist was given protected time within the clinic to tackle medication-related queries, which patients found invaluable.Conclusion: In England, there is just one Consultant Psychiatrist for every 12,600 people. Hence, the demands on clinical services for treatment have become unsustainable. Consequently, a novel and agile approach is required when organising community mental health services, so that all available clinical knowledge and expertise is exploited and geared towards maintaining a high quality of clinical care for patients, despite the resource limitations that are present. This QI project serves to demonstrate the value of effective collaboration between professionals in the pursuit of clinical excellence.

During a single patient journey from admission to hospital discharge, multiple clinical handovers may occur between health professionals from different specialist inpatient teams and between staff at shift changes. Each handover carries a degree of risk for the patient. It is well recognized that poor communication during handovers has resulted in a significant proportion of preventable deaths The aim of our quality improvement (QI) project was to improve the handover process between Scottish Ambulance Service (SAS) staff and Emergency Department (ED) staff for critically unwell and injured patients arriving into resus. In addition, we aimed to improve communication and staff satisfaction with the handover process.By utilizing QI tools such as the model for improvement, process mapping and driver diagrams, change ideas were identified and trialled using inter-professional simulation as part of PDSA (Plan, Do, Study, Act) cycles. This project involved engagement with ED and SAS staff members via online surveys, simulation sessions and staff education.We increased staff satisfaction with the handover process from 24% to 88% and no adverse events relating to our changes were reported.From the information gathered during PDSA cycles, a new standard operating procedure (SOP) for handover in resus was created.

IntroductionPaging systems in Hospitals have been established for some time, but they are now outdated and unreliable. This opinion is shared by the UK government, which has given the NHS...

AimsPhysical health monitoring is paramount to optimal care for psychiatric patients. Blood tests and ECGs are invaluable tests throughout a patient's care. At baseline, they aid investigation of potential organic causes of psychiatric presentations and provide organ and electrolyte status before starting medication. Common psychotropic medications carry physical health risks: bloods and ECGs aid in monitoring potential side effects of prescribed medication.In this local Tier 4 inpatient unit, anecdotal observation revealed completion of these basic investigations was noted to be suboptimal.This project aimed to improve timely completion of baseline (within 72 hours of admission) and monitoring (within one week of due date) bloods and ECGS.MethodThis project was completed within a 12-bed child and adolescent inpatient unit. Using Plan Do Study Act (PDSA) methodology, the multidisciplinary team collated driver diagrams to identify potential areas for intervention. Following baseline analysis, colleague communication was considered key. Consequently, a chart for bloods and ECG completion was created.Each monthly PDSA cycle included the following consecutive interventions: PDSA cycle 1: chart implementationPDSA cycle 2: chart simplification and font size increasePDSA cycle 3: allocated change in team leader for this cyclePDSA cycle 4: Blood request pocket in officePDSA cycle 5: chart simplification through removal of datesPDSA cycle 6: ECG pocketPDSA cycle 7: box on handover listResultMonthly investigations and admission numbers are unpredictable and inconsistent in this cohort: relevant case numbers per PDSA ranged from zero to ten. The results were presented as percentages to allow for direct comparison between cycles.Baseline and results of each consecutive PDSA cycle described above were as follows (N/A represents a cycle where no investigations were required):Admission bloods were completed within 72 hours in 50%, 100%, 50%, 80%, N/A, 100%, 100%, 100%Admission ECG was completed within 72 hours in 30%, 66%, 50%, 70%, N/A, 100%, 100%, 100%Monitoring bloods were completed within one week of due date in 25%, 33%, 0%, 80%, 100%, 100%, 100%, 100%Monitoring ECG was completed within one week of due date in 0%, 0%, N/A, 66%, 100%, 66%, N/A 100%ConclusionThrough close multidisciplinary collaboration and chart implementation, completion of bloods and ECGs improved. Low patient numbers per PDSA cycle resulted in large changes in percentage results, limiting the significance of these findings. Wider implementation of the chart within local Trust inpatient wards is considered.

Objective: Depression is common in adolescents with type 1 (T1D) and type 2 diabetes (T2D) , and for those with T1D, is associated with suboptimal health outcomes, including higher A1c levels and increased rates of hospitalizations. The ADA standards of care recommend integration of depression screening into routine medical care, but follow-up for positive screens is challenging in settings with limited mental health support. Here, we describe our latest PDSA cycle results from a quality improvement (QI) project for implementing depression screening in adolescents with diabetes. Methods: This QI project took place in a pediatric diabetes center without access to mental health support as part of routine diabetes care. Our goals were to 1) increase depression screening via the PHQ-9 from 0% to 80% over 2 years in all patients with T1D or T2D >11 yrs old and 2) refer 100% of patients who screened positive to behavioral health by the end of the 2-year period (Dec 2019-Dec 2021) . Our QI project included 4 Plan-Do-Study-Act (PDSA) cycles ranging from trialing PHQ-9 screening with a single provider (Cycle 1) to implementing screening across all providers (Cycle 4) . This abstract focuses on the last 6 months of PDSA Cycle 4 (previous cycles were presented at 2021 ADA Scientific Sessions) . Results: From July-Dec. 2021, a total of 68% of eligible patients completed PHQ-9 screening. Screening rates ranged from 46-90% across 5 different providers; 2 providers achieved screen rate goal of >80%. Of the 68%, 28% screened positive and 86% of them were referred to behavioral health. Referral rates for positive screens ranged from 83-100% per provider; 2 providers achieved refer rate goal of 100%. Conclusions: Although we did not achieve our PHQ-9 screen rate goal of 80% or our behavioral health refer rate goal of 100% by the end of 2 years, we found a major discrepancy in rates among providers. This prompted us to add an additional PDSA Cycle 5, which focuses on improving screening and refer rates for all providers. Disclosure S. Gurnurkar: None. A. Y. Kulasingham: None. J. Pierce: None.

End-stage liver disease (ESLD) is a terminal diagnosis with a poor prognosis and an accelerating mortality rate in the UK. Limited research suggests that patients with ESLD have unmet palliative care (PC) needs, likely due to various factors, including difficulty predicting prognosis and lack of clear specialist palliative care (SPC) referral criteria.This quality improvement (QI) project aimed to assess and improve access to PC for inpatients with ESLD and unmet PC needs over a 6-month period using a novel intervention incorporating the Supportive and Palliative Care Indicators Tool for Liver Disease (SPICT). The project was conducted at a tertiary centre between 2020 and 2022 with three data cycles: one baseline measurement and two Plan-Do-Study-Act (PDSA) cycles. PDSA cycle 1 involved regular screening of inpatients using the SPICT to trigger SPC referral. PDSA cycle 2 also involved screening using the SPICT, but instead to prompt multidisciplinary meeting (MDM) discussion between hepatology and SPC teams. Outcome measures reflecting holistic aspects of PC were assessed across all cycles. PDSA cycle 1 demonstrated a significant reduction in patients receiving no PC measures (67% to 26%, p: <0.001) and increased SPC input (32% to 52%, p: 0.04). Community PC referrals also rose significantly (13% to 39%, p: 0.01).PDSA cycle 2 failed to improve measures compared to baseline. Only 42% of eligible patients were discussed in the MDM. Most agreed plans were implemented, but only a minority included SPC review, community PC referral or advanced care planning. Patients with ESLD continued to have unmet PC needs despite implementing an intervention based on expert guidance. PDSA cycle 1 demonstrated some significant, positive impacts, supporting the clinical utility of the SPICT, but within the context of a small, single-centre QI project with methodological limitations.

Randomized controlled trials have shown that adequate vitamin D supplementation in nursing home (NH) residents reduces the rates of falls and fractures. In our NH, review of medication administration records of all patients (n = 101) revealed that only 34.6% of the patients were currently prescribed adequate doses of vitamin D, revealing a need for intervention. We designed a Quality Improvement (QI) project with the objective of improving the vitamin D prescription rate in our NH. We used the Plan-Do-Study-Act (PDSA) approach to implement this QI project. Patients not currently prescribed an adequate dose of vitamin D were identified and started on a daily dose of 800 IU of vitamin D. Additionally, patients who were experiencing falls while on an adequate dose of vitamin D for 3 months were examined for the possibility of vitamin D deficiency and were started on 50,000 IU of vitamin D per week for 12 weeks if they were found to be vitamin D-deficient based on blood levels of 25-hydroxy-vitamin D below 30 ng/mL. We found that with several PDSA cycles over a period of 5 months, the prescription rate for vitamin D was increased to 86%, surpassing our initial goal of 80%. In conclusion, we found that a multidisciplinary QI program utilizing multiple PDSA cycles was effective in reaching target prescription rates for vitamin D supplementation in a population of NH patients.

BackgroundUnderstanding the effect of analgesia on pain helps guide management (Jenson, 2003). This recognition led to the creation of pain assessment tools (Hølen, Hjermstad, Loge, Fayers, et al., 2006; Hjermstad,...

Objectives To improve monthly milk donation by 30% from 25.4 L to 33 L over 17 months in a comprehensive lactation management center (CLMC) and to study its implications on postnatal and postoperative ward neonates. Material and Methods This is a quality improvement (QI) project, conducted from Jan 2022 to May 2024 in three phases: Baseline (Jan-Dec 2022), Intervention (Jan-Dec 2023), and sustenance (Jan-May 2024). A QI team was formed and factors for reduced milk donation were identified. Interventions were planned in two PDSA (Plan Do study Act) cycles to improve awareness among mothers and staff nurses of postnatal (PN)-Postop ward regarding benefits of breastmilk, human milk bank, PDHM, increasing nutrition of mothers and to improve milk collection facilities. The monthly outcome measures were number of donors, average volume of milk collected, volume of milk disbursed, number of beneficiaries, the rate of exclusive breastfeeding, morbidities &amp; mortality in PN-Postoperative ward. Study variables of all three phases were analyzed using QI macros 2020. Results The mean (SD) monthly donated milk volume increased from 25.4L (2.5) in baseline to 40.0 L(2.4) and 39.3L (1.03) in intervention and sustenance phase respectively (P &lt; 0.0001). Milk disbursed to PN-Postop ward increased from 6.4L (1.1) in baseline phase to 13.1L(3.8) and 14.5L (0.54) in subsequent phases. Beneficiaries increased from 43(35-49.7) to 68(56.7-77) and 110 (105-120). Exclusive breastfeeding rates improved from 70% to 97% and 99%. Postnatal admissions due to sepsis, feed intolerance, or dehydration decreased from 25.5(23.7-26) to 5(4-6.2) and 5(5-5) after intervention (P &lt; 0.001). Mortality decreased from 0.049% in baseline to 0.016% in intervention phase. However, there were no deaths in sustenance phase (P = 0.011). Conclusion QI measures help to motivate more mothers to donate more milk. This improves number of beneficiaries and volume of milk disbursed to neonates in postnatal &amp; postoperative ward which improves their outcomes.

Introduction:Using plan-do-study-act (PDSA) cycles, this quality improvement (QI) project aimed to standardize an anesthetic protocol to optimize multimodal pain management for pediatric open inguinal hernia repair (OIHR).Methods:PDSA cycle 1: in December 2017, we standardized the intraoperative OIHR anesthesia protocol by replacing transversus abdominis plane (TAP) or ilioinguinal-iliohypogastric (II) blocks and fentanyl with exclusively II blocks and fentanyl. PDSA cycle 2: in January 2019, we used an opioid sparing strategy, replacing II blocks and fentanyl with II blocks and dexmedetomidine. We used statistical process control (SPC) charts to analyze data from the medical record. Outcome measures included the percent of patients requiring rescue morphine in the postanesthesia care unit (PACU), maximum PACU pain score, PACU length of stay (LOS), and anesthesia preparation duration.Results:The team performed a total of 641 pediatric OIHRs between July 2015 and June 2021. The three groups included 203 patients in our baseline group, 127 patients in the PDSA cycle 1 group, and 311 patients in the PDSA cycle 2 group. Special cause variation (SCV) occurred for the percent of patients requiring rescue morphine, anesthesia preparation duration, and PACU LOS. The percent of patients requiring rescue morphine showed improvement. Anesthesia preparation duration improved compared to baseline. There was no SCV detected in the SPC chart for maximum PACU pain score.Conclusion:We implemented an opioid sparing anesthetic protocol for pediatric OIHR utilizing II blocks and dexmedetomidine without adversely affecting postoperative pain score or morphine rescue rate over 6 years.