Adoption Of Quality Improvement Research Articles

Statewide Perinatal Quality Improvement, Teamwork, and Communication Activities in Oklahoma and Texas.

The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas. In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation. Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001). Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units.

Quality improvement in the voluntary sector: knowledge, capacity and education

Quality improvement has been proposed as a means of enhancing health and social care on an international scale. Despite being a key stakeholder in health and social care delivery, there is a lack of evidence regarding the adoption of quality improvement in the voluntary sector. For this study, 21 semi-structured interviews and five focus groups were conducted with Scottish voluntary sector staff. A gap analysis was undertaken, and findings were used to co-create educational sessions that may aid capacity building. Our findings suggest that knowledge, adoption and practice of quality improvement are currently variable in the Scottish voluntary sector. Capacity building for improvement is most successful when supported with sector-specific examples and networking opportunities. We conclude that the current policy landscape provides an opportunity for national governments to involve the voluntary sector as an equal partner in the adoption of quality improvement. We make recommendations for researchers and policy makers on how this may be achieved.

Actions to improve quality: results from a national hospital survey.

CMS measures and reports hospital performance to drive quality improvement (QI), but information on actions that hospitals have taken in response to quality measurement is lacking. We aimed to develop national estimates of QI actions undertaken by hospitals and to explore their relationship to performance on CMS quality measures. Nationally representative cross-sectional survey of acute care hospitals in 2016 (n = 1313 respondents; 64% response rate). We assessed 23 possible QI changes. Using multivariate linear regression, we estimated the relationship between reported QI changes and performance on composite measures derived from 26 Hospital Inpatient Quality Reporting Program measures (scaled 0-100), controlling for case mix and facility characteristics. Hospitals reported implementing a mean of 17 QI changes (median [interquartile range], 17 [15-20]). Large hospitals reported significantly higher adoption rates than small hospitals for 18 QI changes. Most hospitals that reported making QI changes (63%-96% for the 23 changes) responded that the specific change made helped improve performance. In multivariate regression analyses, adoption of 92% of QI changes (90th percentile among hospitals), compared with adoption of 50% of QI changes (10th percentile), was associated with a 2.3-point higher overall performance score (95% CI, 0.7-4.0) and higher process (8.7 points; 95% CI, 5.7-11.7) and patient experience (3.0 points; 95% CI, 0.1-5.9) composite scores. Hospitals reported widespread adoption of QI changes in response to CMS quality measurement and reporting. Higher QI adoption rates were associated with modestly higher process, patient experience, and overall performance composite scores.

Home health agency adoption of quality improvement activities and association with performance.

The Centers for Medicare & Medicaid Services (CMS) Home Health Quality Reporting Program (HHQRP) uses performance measurement to spur improvements in home health agencies' (HHAs') quality of care. We examined quality improvement (QI) activities HHAs reported making to improve on HHQRP quality measures, and whether reported QI activities were associated with better measure performance. We used responses (N= 1052) from a Web- and mail-based survey of a stratified random sample of HHAs included in CMS Home Health Compare in October 2019. We estimated national adoption rates for 27 possible QI activities related to organizational culture, health information technology, care process redesign, provider incentives, provider training, changes to staffing responsibilities, performance monitoring, and measure-specific QI initiatives and technical assistance. We used multivariate linear regression to examine the associations between HHA characteristics and QI adoption, and between QI adoption and CMS Home Health Quality of Patient Care Star Rating. HHAs reported implementing an average of 16 QI activities (interquartile range 11-19 activities). Larger HHA size was associated with adopting 1.6 additional QI activities (p< 0.001). HHAs with higher proportions of disabled, black, or Hispanic patients adopted QI activities at similar or higher rates as other HHAs. Of the 27 QI activities, 23 were considered helpful by more than 80% of adopting HHAs. Compared with adopting 44% of QI activities (10th percentile among HHAs), adopting 89% of QI activities (90th percentile) was associated with a 0.4-star higher Star Rating (95% confidence interval 0.2-0.6). HHAs report implementing a significant number of QI activities in response to CMS measurement programs; implementation of a greater number of activities is associated with better performance on publicly reported measures. To guide future HHA QI investments, work is needed to identify the optimal combination of QI activities and the specific QI activities that yield the greatest performance improvements.

Economics of the Management of Craniospinal Chordoma and Chondrosarcoma and the feasibility of the bundled payment model

BackgroundThe Centers for Medicare and Medicaid Services (CMS) created a new reimbursement model “Bundled Payment for Care Improvement (BPCI)” which reimburses providers a predetermined payment in advance to cover all possible services rendered within a certain time window. Chordoma and Chondrosarcoma are locally aggressive malignant primary bony tumors. Treatment includes surgical resection and radiotherapy with substantial risk for recurrence which necessitates monitoring and further treatment. We assessed the feasibility of the BPCI model in these neurosurgical diseases.MethodsWe selected patients with chordoma/chondrosarcoma from inpatient admission table using the International Classification of Disease, 9th (ICD-9), and 10th (ICD-10) revision codes. We collected the patients’ demographics and insurance type at the index hospitalization. We recorded the following outcomes length of stay, total payment, discharge disposition, and complications for the index hospitalization. For post-discharge, we collected the 30 days and 3/6/12 months inpatient admission, outpatient service, and medication refills. Continuous variables were summarized by means with standard deviations, median with interquartile and full ranges (minimum-maximum); Continuous outcomes were compared by nonparametric Wilcoxson rank-sum test. All tests were 2-sided with a significance level of 0.05. Statistical data analysis was performed in SAS 9.4 (SAS Institute, Inc, Cary, NC).ResultsThe population size was 2041 patients which included 1412 patients with cranial (group1), 343 patients with a mobile spine (group 2), and 286 patients with sacrococcygeal (group 3) chordoma and chondrosarcoma. For index hospitalization, the median length of stay (days) was 4, 6, and 7 for groups 1, 2, and 3 respectively (P<.001). The mean payments were ($58,130), ($84,854), and ($82,440), for groups 1, 2, and 3 respectively (P=.02). The complication rates were 30%, 35%, and 43% for groups 1, 2, and 3 respectively (P<.001). Twelve months post-discharge, the hospital readmission rates were 44%, 53%, and 65% for groups 1, 2, and 3, respectively (P<.001). The median payments for this period were ($72,294), ($76,827), and ($101,474), for groups 1, 2, and 3, respectively (P <.001).ConclusionThe management of craniospinal chordoma and chondrosarcoma is costly and may extend over a prolonged period. The success of BPCI requires a joint effort between insurers and hospitals. Also, it should consider patients’ comorbidities, the complexity of the disease. Finally, the adoptionof quality improvement programs by hospitals can help with cost reduction.

Integrated and Collaborative Care: Quality Improvement in Action

The popularity of Integrated and Collaborative Care (ICC) treatment models in behavioral health has paralleled the growth of the Quality Improvement (QI) movement in the American health care system. QI entails continuous and organized efforts to improve the performance of a system. These concepts are closely related, and in many ways ICC can be seen as a specific application of QI principles. In addition, these concepts are synergistic in that ICC programs can be implemented with QI tools, and such programs also create numerous opportunities for further QI efforts. The broader adoption of QI will help drive innovation in psychiatric care delivery. [ Psychiatr Ann . 2017;47(7):374–377.]

Are Evidence-based Practices Associated With Effective Prevention of Hospital-acquired Pressure Ulcers in US Academic Medical Centers?

In 2008, the Centers for Medicare and Medicaid Services (CMS) established nonpayment policies resulting from costliness of hospital-acquired pressure ulcers (HAPUs) to hospitals. This prompted hospitals to adopt quality improvement (QI) interventions that increase use of evidence-based practices (EBPs) for HAPU prevention. To evaluate the longitudinal impact of CMS policy and QI adoption on HAPU rates. We characterized longitudinal adoption of 25 QI interventions that support EBPs through hospital leadership, staff, information technology, and performance and improvement. Quarterly counts of HAPU incidence and inpatient characteristics were collected from 55 University HealthSystem Consortium hospitals between 2007 and 2012. Mixed-effects regression models tested the longitudinal association of CMS policy, HAPU coding, and QI on HAPU rates. The models assumed level-2 random intercepts and random effects for CMS policy and EBP implementation to account for between-hospital variability in HAPU incidence. Controlling for all 25 QI interventions, specific updates to EBPs for HAPU prevention had a significant, though modest reduction on HAPU rates (-1.86 cases/quarter; P=0.002) and the effect of CMS nonpayment policy on HAPU prevention was much greater (-11.32 cases/quarter; P<0.001). HAPU rates were significantly lower after changes in CMS reimbursement. Reductions are associated with hospital-wide implementation of EBPs for HAPU prevention. Given that administrative data were used, it remains unknown whether these improvements were due to changes in coding or improved quality of care.

Integrating Quality Improvement and Continuing Professional Development: A Model From the Mental Health Care System.

To explore the perspectives of leaders in psychiatry and continuing professional development (CPD) regarding the relationship, opportunities, and challenges in integrating quality improvement (QI) and CPD. In 2013-2014, the authors interviewed 18 participants in Canada: 10 psychiatrists-in-chief, 6 CPD leaders in psychiatry, and 2 individuals with experience integrating these domains in psychiatry who were identified through snowball sampling. Questions were designed to identify participants' perspectives about the definition, relationship, and integration of QI and CPD in psychiatry. Interviews were recorded and transcribed. An iterative, inductive method was used to thematically analyze the transcripts. To ensure the rigor of the analysis, the authors performed member checking and sampling until theoretical saturation was achieved. Participants defined QI as a concept measured at the individual, hospital, and health care system levels and CPD as a concept measured predominantly at the individual and hospital levels. Four themes related to the relationship between QI and CPD were identified: challenges with QI training, adoption of QI into the mental health care system, implementation of QI in CPD, and practice improvement outcomes. Despite participants describing QI and CPD as mutually beneficial, they expressed uncertainty about the appropriateness of aligning these domains within a mental health care context because of the identified challenges. This study identified challenges with aligning QI and CPD in psychiatry and yielded a framework to inform future integration efforts. Further research is needed to determine the generalizability of this framework to other specialties and health care professions.

Increased Adoption of Quality Improvement Interventions to Implement Evidence-Based Practices for Pressure Ulcer Prevention in U.S. Academic Medical Centers.

In 2008, the U.S. Centers for Medicare and Medicaid Services enacted a nonpayment policy for stage III and IV hospital-acquired pressure ulcers (HAPUs), which incentivized hospitals to improve prevention efforts. In response, hospitals looked for ways to support implementation of evidence-based practices for HAPU prevention, such as adoption of quality improvement (QI) interventions. The objective of this study was to quantify adoption patterns of QI interventions for supporting evidence-based practices for HAPU prevention. This study surveyed wound care specialists working at hospitals within the University HealthSystem Consortium. A questionnaire was used to retrospectively describe QI adoption patterns according to 25 HAPU-specific QI interventions into four domains: leadership, staff, information technology (IT), and performance and improvement. Respondents indicated QI interventions implemented between 2007 and 2012 to the nearest quarter and year. Descriptive statistics defined patterns of QI adoption. A t-test and statistical process control chart established statistically significant increase in adoption following nonpayment policy enactment in October 2008. Increase are described in terms of scope (number of QI domains employed) and scale (number of QI interventions within domains). Fifty-three of the 55 hospitals surveyed reported implementing QI interventions for HAPU prevention. Leadership interventions were most frequent, increasing in scope from 40% to 63% between 2008 and 2012; "annual programs to promote pressure ulcer prevention" showed the greatest increase in scale. Staff interventions increased in scope from 32% to 53%; "frequent consult driven huddles" showed the greatest increase in scale. IT interventions increased in scope from 31% to 55%. Performance and improvement interventions increased in scope from 18% to 40%, with "new skin care products . . ." increasing the most. Academic medical centers increased adoption of QI interventions following changes in nonpayment policy. These QI interventions supported adherence to implementation of pressure ulcer prevention protocols. Changes in payment policies for prevention are effective in QI efforts.

Factors driving the adoption of quality improvement initiatives in local health departments: results from the 2010 profile study.

Over the past decade, quality improvement (QI) has become a major focus in advancing the goal of improving performance of local health departments (LHDs). However, limited empirical data exists on the current implementation of QI initiatives in LHDs and factors associated with adoption of QI initiatives. (1) To examine the current implementation of QI implementation initiatives by LHDs and (2) to identify factors contributing to LHDs' decision to implement QI initiatives. In this study, a novel theoretical framework based on analysis of QI in medicine was applied to analyze QI by LHDs. LHDs' QI adoption was assessed by the number of formal QI projects reported by LHDs that responded to module 1 of the 2010 National Profile of Local Health Department Study (Profile Study) conducted by the National Association of County & City Health Officials. The Profile Study data were merged with data from the Health Resources and Services Administration's Area Resource Files and the Association of State and Territorial Health Officials' 2010 Survey. Logistic regression analyses were conducted using Stata 11 SVY procedure to account for the complex sampling design. The Profile Study data indicated that about 73% of the LHDs reported implementing 1 or more QI projects. LHDs with large jurisdiction population (>50 000), higher per capita public health expenditure, a designated QI staff member, or prior participation in performance improvement programs were more likely to have undertaken QI initiatives. According to the Profile Study, more than a quarter of LHDs surveyed did not report implementing any formal QI projects. Greater investments in QI programs and designation of QI staff can be effective strategies to promote QI adoption. The validity of the definition of a formal QI project needs to be established. More research to identify the barriers to successful QI implementation at LHDs is also needed.

Deciphering the imperative: translating public health quality improvement into organizational performance management gains.

With the launching of the national public health accreditation program under the auspices of the Public Health Accreditation Board (PHAB), health department momentum around quality improvement adoption has accelerated. Domain 9 of the PHAB standards (one of 12 domains) focuses on evaluation and improvement of performance and is acting as a strong driver for quality improvement and performance management implementation within health departments. Widespread adoption of quality improvement activities in public health trails that in other US sectors. Several performance management models have received broad acceptance, including models among government and nonprofits. A model specifically for public health has been developed and is presented herein. All models in current use reinforce customer focus; streamlined, value-added processes; and strategic alignment. All are structured to steer quality improvement efforts toward organizational priorities, ensuring that quality improvement complements performance management. High-performing health departments harness the synergy of quality improvement and performance management, providing powerful tools to achieve public health strategic imperatives.

Healthcare technologies, quality improvement programs and hospital organizational culture in Canadian hospitals

BackgroundHealthcare technology and quality improvement programs have been identified as a means to influence healthcare costs and healthcare quality in Canada. This study seeks to identify whether the ability to implement healthcare technology by a hospital was related to usage of quality improvement programs within the hospital and whether the culture within a hospital plays a role in the adoption of quality improvement programs.MethodsA cross-sectional study of Canadian hospitals was conducted in 2010. The sample consisted of hospital administrators that were selected by provincial review boards. The questionnaire consisted of 3 sections: 20 healthcare technology items, 16 quality improvement program items and 63 culture items.ResultsRasch model analysis revealed that a hierarchy existed among the healthcare technologies based upon the difficulty of implementation. The results also showed a significant relationship existed between the ability to implement healthcare technologies and the number of quality improvement programs adopted. In addition, culture within a hospital served a mediating role in quality improvement programs adoption.ConclusionsHealthcare technologies each have different levels of difficulty. As a consequence, hospitals need to understand their current level of capability before selecting a particular technology in order to assess the level of resources needed. Further the usage of quality improvement programs is related to the ability to implement technology and the culture within a hospital.

Quality Improvement in North Carolina’s Public Health Departments

North Carolina has been a leader in the application of quality improvement (QI) to public health practice. Over the past decade, numerous developments have served to accelerate the adoption of QI in North Carolina's local health departments. The outstanding results from the widespread application of QI should help North Carolina to become a healthier state.

A nationwide quality improvement project to accelerate Ghana's progress toward Millennium Development Goal Four: design and implementation progress

The gap between evidence-based guidelines and practice of care is reflected, in low- and middle-income countries, by high rates of maternal and child mortality and limited effectiveness of large-scale programing to decrease those rates. We designed a phased, rapid, national scale-up quality improvement (QI) intervention to accelerate the achievement of Millennium Development Goal Four in Ghana. Our intervention promoted systems thinking, active participation of managers and frontline providers, generation and testing of local change ideas using iterative learning from transparent district and local data, local ownership and sustainability. After 50 months of implementation, we have completed two prototype learning phases and have begun regional spread phases to all health facilities in all 38 districts of the three northernmost regions and all 29 Catholic hospitals in the remaining regions of the country. To accelerate the spread of improvement, we developed 'change packages' of rigorously tested process changes along the continuum of care from pregnancy to age 5 in both inpatient and outpatient settings. The primary successes for the project so far include broad and deep adoption of QI by local stakeholders for improving system performance, widespread capacitation of leaders, managers and frontline providers in QI methods, incorporation of local ideas into change packages and successful scale-up to approximately 25% of the country's districts in 3 years. Implementation challenges include variable leadership uptake and commitment at the district level, delays due to recruiting and scheduling barriers, weak data systems and repeated QI training due to high staff turnover.

Quality Improvement in Local Health Departments

To assess the current status of quality improvement (QI) within local health departments (LHDs) and examine the characteristics associated with such QI efforts. A QI module was administered to a representative sample of 545 LHDs along with the core instrument in the 2008 NACCHO Profile survey of all LHDs nationally. Using the Profile survey data set, a quantitative approach was employed to determine the current status of QI within LHDs. Statistical analysis was performed to identify characteristics of LHDs associated with QI. The response rate to the QI module was 82 percent. Of the 448 LHDs that responded to the QI Module, 55 percent reported conducting formal QI efforts during the previous 2 years. Forty-four percent of these LHDs used a specific framework for QI, 56 percent used at least one of four commonly employed QI tools or techniques, and customer focus and satisfaction was the most frequently reported area (76%) of QI efforts. LHDs with large size of jurisdiction population and those with centralized governance were more likely to have engaged in quality or performance improvement, have managers who received formal QI training, and have provided QI training to staff. The 2008 NACCHO Profile QI module furnishes an excellent baseline for measuring progress of health department QI activities as accreditation and other related activities intensify. A clear definition of QI in public health that is understood by practitioners will greatly increase our ability to measure the adoption of QI by LHDs. Further research is necessary to identify and explore some of the predictors and possible barriers to increasing the application of QI by LHDs.

Review and Analysis of Quality Improvement Techniques in Police Departments

This qualitative study reviews and analyzes quality improvement (QI) techniques in police departments as a background for assessing ways to introduce QI into public health departments. Police departments and public health departments have many elements in common. These findings provide some understanding of how public health departments can incorporate QI methods as well as learn about the potential barriers to implementing QI projects that are inherent in government agencies. The study consists of extensive interviews of informants from academic settings and police departments across the nation. The findings describe (1) the extent of QI diffusion into police departments, (2) barriers and enablers of QI diffusion in police departments, (3) a typology of QI diffusion, and (4) the metrics and incentives to promote QI in the absence of profit motives. Seven specific recommendations are made to promote the application and adoption of QI in public health: (1) implement QI as a comprehensive management approach, (2) top official involvement, (3) a broad focus on mission and vision, (4) lessons for overcoming barriers, (5) how to find resources, (6) how to integrate proven methods, and (7) how to build on existing capabilities.

Quality management approaches in Irish organisations

PurposeThe objectives of this study were to investigate the degree to which quality initiatives, including quality standards, have been adopted in Irish organisations and to provide comparisons with survey results of surveys in 1995/1996.Design/methodology/approachA national survey was conducted in 2002 of Irish employers in manufacturing/services within the private and public sectors. The questionnaire was sent to 2,487 organisations – 932 questionnaires were returned representing a 34 per cent response rate from the private sector organisations and 47 per cent in the public sector.FindingsThe survey illustrates the continuing importance of, and reliance upon, standards. Among organisations that had been awarded ISO 9000 certification, 93 per cent believed that it had improved their reputation and 90 per cent that it resulted in better products or services. Nearly two‐thirds of respondent organisations had adopted a total quality approach compared with less than one‐third in 1995/1996. The results demonstrate that total quality organisations did not differ significantly from non‐TQ organisations in relation to having been awarded ISO 9000. However, there were statistically significant differences between TQ and non‐TQM organisations in relation to: a commitment to quality, quality structures, measures to evaluate effectiveness in relation to customers, employees and suppliers, team working, quality assurance systems, use of quality tools and techniques and investment in training.Originality/valueThis study shows that interest and adoption of quality improvement in Irish organisations is growing rapidly, particularly since the mid‐1990s that has marked a distinct period of economic growth in the Irish economy.

Does medical culture limit doctors' adoption of quality improvement? Lessons from Camelot

This paper analyses aspects of medical culture, explains why this culture is antagonistic to quality improvement, and provides solutions to help medical colleges meet the challenge of clinical governance. Like the knights of Camelot, doctors have their own all-pervading culture, occupationally centred, exclusive to the initiated and tending to the traditional, either overtly or through assumed values. The Camelot metaphor is supported by analysis of empirical evidence, especially the documents produced by medical colleges. Suggested initiatives to overcome these organisational barriers include improvements in continuing medical education, accreditation, guideline production and responsibility for the performance of doctors. Central to these improvements should be the involvement of every doctor, via the Delphi process, and substantial contributions to college processes from other health care professions and patients.

An evidence-based national quality measurement and reporting system.

Evidence-based medicine and evidence-based guidelines are widely supported among physicians and other health professionals, although practice may still fall far short of the ideas contained in the concept. Insufficient attention has been given to using the concepts of evidence-based practice in the selection of measures, diffusion of innovations, and adoption of quality improvement (QI) techniques. To describe in greater detail how evidence serves as a foundation for a national quality measurement and reporting system (NQMRS) and to consider the different types of evidence that will be used. The role of the NQMRS in adding to the evidence base is explored. A descriptive, conceptual discussion. Many different types of evidence are available for use in the NQMRS. The NQMRS could add substantial new evidence on how well different approaches to quality measurement, reporting, and improvement work and also expand the evidence base on the effectiveness of clinical interventions for which efficacy has been established. An evidence-based NQMRS will require substantial leadership from government and private entities. The gains from a greater focus on evidence are expected to be found in accelerating QI. Reliance on evidence-based approaches should not be used to stifle innovation.