Applying Quality Improvement Methods Research Articles

A Learning Community Supporting Experiential Education to Learn About Healthcare Equity Quality Improvement.

Quality improvement (QI) for healthcare equity (HCE) is an important aspect of graduate medical education (GME), but there is limited published research on educational programs teaching this topic. To describe and evaluate a novel curriculum and learning community for HCE QI. Academic institution. Forty-eight participants: 32 learners and 16 faculty. This novel, longitudinal curriculum utilized a virtual hub-and-spoke learning community. Five interdepartmental teams of learners and faculty (spokes) used QI methods to address an existing institutional healthcare inequity (HCI). A team of experts (the hub) led monthly group meetings to foster the learning community and guide teams. Retrospective pre-post curricular surveys assessed participant satisfaction, knowledge, and skills in applying QI methods to address HCIs. Response rate was 33%. The majority of participants (92.4%) reported an increase in knowledge and skills in conducting QI for HCIs. All participants reported an increased likelihood of future engagement in HCE QI. Final QI projects average QIPAT7 score was 25.8 (SD = 4.93), consistent with "meets expectations" in most categories. This program is a feasible model to teach GME learners and faculty about HCE QI and may be adopted by other institutions.

Quality Improvement in Itself Changes Your Thinking: Lessons From Disseminating Quality Improvement Methods Through a Multisite International Collaborative Palliative Care Project in India.

Seven major palliative care (PC) centers in India were mentored through the Palliative Care-Promoting Assessment and Improvement of the Cancer Experience (PC-PAICE) by US and Australian academic institutions to implement a quality improvement (QI) project to improve the accessibility and quality of PC at their respective centers. The objective was to evaluate the experiences of teams in implementing QI methods across diverse geographical settings in India. A quota sampling approach was used to elicit perspectives of local stakeholders at each site. The Consolidated Framework for Implementation Research informed development of a semistructured interview guide. Analysis leveraged deductive and inductive approaches. We interviewed 44 participants (eight organizational leaders, 12 clinical leaders, and 24 team members) at seven sites and identified five themes. (1) Implementing QI methods enabled QI teams to think analytically to solve a complex problem and to identify resources. (2) Developing a problem statement by identifying specific gaps in patient care fostered team collaboration toward a common goal. (3) Making use of QI tools (eg, A3 process) systematically provided a new, straightforward QI toolkit and improved QI teams' conceptual understanding. (4) Enhancing stakeholder engagement allowed shared understanding of QI team members' roles and processes and shaped interventions tailored to the local context. (5) Designing less subjective processes for patient care such as assessment scales to identify patient's symptomatic needs positively changed work practices and culture. Engaging and empowering multiple stakeholders to use QI methods facilitated the expansion and improvement of PC and cancer services in India. PC-PAICE demonstrated an efficient, effective way to apply QI methods in an international context. The impact of PC-PAICE is being magnified by developing a cadre of Indian QI leaders.

A Clinician's Guide to Artificial Intelligence (AI): Why and How Primary Care Should Lead the Health Care AI Revolution.

Artificial intelligence (AI) in health care is the future that is already here. Despite its potential as a transformational force for primary care, most primary care providers (PCPs) do not know what it is, how it will impact them and their patients, and what its key limitations and ethical pitfalls are. This article is a beginner's guide to health care AI, written for the frontline PCP. Primary care-as the dominant force at the base of the health care pyramid, with its unrivaled interconnectedness to every part of the health system and its deep relationship with patients and communities-is the most uniquely suited specialty to lead the health care AI revolution. PCPs can advance health care AI by partnering with technologists to ensure that AI use cases are relevant and human-centered, applying quality improvement methods to health care AI implementations, and advocating for inclusive and ethical AI that combats, rather than worsens, health inequities.

Quality improvement in practice—part 1: creating learning systems

Applying quality improvement methods to solve complex quality issues involves people deeply. People discover solutions, test and adapt ideas, thereby giving them autonomy and control over the system in which they work. Focusing quality improvement on what matters most for staff and service users creates the opportunity to bring a deeper sense of meaning and connection to purpose, both of which are integral to joy in work. When applying quality improvement at scale within large organisations or systems, bringing teams together in learning systems can provide a critical structure to build skills, collaborate and learn from one another. This article describes the core elements of learning systems designed to support quality improvement and joy in work, illustrated through two examples. The framework can be applied at different levels of a system, including the individual, the team and the organisation, or even to a large improvement effort across organisational boundaries. The next article in this series will discuss the application of the joy in work framework to healthcare settings.

Abstract 49: Building a Culture of Quality Improvement at Butaro Cancer Center of Excellence in Rwanda

Abstract Purpose: As access to cancer care expands in sub-Saharan Africa, it is essential to develop strategies to examine and improve cancer care quality. We designed and implemented a quality improvement (QI) training and mentorship program for clinicians at Butaro Cancer Center of Excellence (BCCOE) in Rwanda to foster a culture of continual improvement. We report our early experience. Methods: The BCCOE QI curriculum was adapted from programs from Dana-Farber Cancer Institute and Partners In Health-Rwanda and included didactic training, mentored QI projects and leadership development. Prior to the program, staff QI needs, experiences and perspectives were assessed through two focus group discussions (FGDs) with 18 participants. Written surveys assessed staff QI self-efficacy and knowledge immediately before and after a one-day training. Three BCCOE clinicians selected as QI mentors received an additional 3-day intensive training and longitudinal coaching by Rwanda- and US-based QI coaches. Mentors worked with clinician colleagues and coaches to identify quality gaps and devise and implement metric-based QI projects. Results: FGD participants expressed eagerness to engage in QI efforts but identified challenges to QI implementation, including insufficient time, staff and financial resources. Forty oncology staff members (70% nurses) participated in one-day didactic trainings; 37 completed pre- and post-surveys. Perceived QI knowledge, confidence applying QI methods, and perception of adequate time for QI improved after the training (p<0.001 for all using paired t-tests). Mean performance on knowledge assessment items increased from 64% to 73% (p=0.001). Mentor-led teams designed and launched projects to: improve cancer staging/documentation before treatment; increase chemotherapy order double-checking; and reduce chemotherapy wait times. Conclusions: BCCOE's QI program has engaged oncology clinicians as QI leaders and participants, building a culture of team-based QI. Didactic training increased staff self-efficacy and knowledge, facilitating successful launch of projects. Future assessments will examine staff experience, attitudes and knowledge after project engagement. Citation Format: Fidele Sebahungu, David Tuyisenge, Lori Buswell, Olivier Habimana, Esperance Benemariya, Fred Mugabo, Aphrodis Ndayisaba, Cyprien Shyirambere, Hubert Tuyishime, Yeonsoo Sara Lee, Catherine Stauber, Jessica Cleveland, Sarah Kadish, Spyridon Potiris, Dan Gunderson, Temidayo Fadelu, Jean Bosco Bigirimana, Anatole Manzi, Lydia Pace. Building a Culture of Quality Improvement at Butaro Cancer Center of Excellence in Rwanda [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 49.

Applying Quality Improvement Methods to Decrease Bowel Obstruction Complications After Total Joint Arthroplasty

BACKGROUND: Though infrequent, bowel obstruction complications after total joint arthroplasty (TJA) can cause significant patient morbidity and mortality. There are few reports of prevention protocols for these complications in current literature. The purposes of this study were to (1) create a protocol to prevent bowel obstruction complications in TJA patients using the Plan-Do-Study-Act (PDSA) quality improvement model as well as (2) assess the effect of the protocol on the incidence of such complications. METHODS: The protocol was created by a multidisciplinary task force at a single specialty orthopedic hospital. Gastrointestinal complications were monitored after implementation of the protocol. The protocol was continually evaluated for problems and modifications were made as necessary. RESULTS: The protocol was implemented in May 2018. From that time until the end of the year, there was a 31.9% decrease in cases of ileus and no cases of bowel obstruction or perforation were observed. CONCLUSION: Bowel obstruction complications after TJA adversely affect patient outcomes. This study describes a standardized protocol created via the PDSA method of quality improvement that aims to prevent these complications in this patient population through early identification and intervention. Given the growing demand of TJA, future research should focus on further standardization of postoperative care in efforts to improve patient outcomes and reduce healthcare costs.

A National Survey of Integrated Vascular Surgery Residents' Experiences With and Attitudes About Quality Improvement During Residency

Integrated vascular surgery residency, or "0+5," programs provide education in the Accreditation Council for Graduate Medical Education (ACGME) competencies of Systems-Based Practice (SBP) and Practice-Based Learning and Improvement (PBLI), which include milestones related to quality improvement (QI). It is unclear what QI curricula are in place in 0+5 programs nationally or how 0+5 residents perceive the importance of QI. The purpose of this study is to assess current 0+5 residents' knowledge, experiences with, and attitudes about QI. A survey was developed using the ACGME Common Program Requirements and Milestones pertaining to QI. All 0+5 residents from 2017 to 2018 academic year were emailed an electronic link to the survey. Descriptive statistics and cross-tabulations were calculated using Stata/MP version 13.1. All 0+5 vascular surgery residency programs in the United State (n = 52). The survey was completed by 35% (n = 90/257) of 0+5 residents, representing 75% of 0+5 programs in the United States (n = 39/52). Forty-one percent of respondents felt that applying QI methods is very important and 33% felt that QI education is very important for their future work, however, just 13% felt very prepared to lead a QI initiative. Residents' perceptions of preparedness to lead QI projects and the importance they attached to QI education were significantly influenced by their participation in a QI project (p = 0.003 and p = 0.038 respectively). Finally, just 8% (n = 6) of residents responded correctly to all 13 knowledge-based questions and these residents felt better prepared to lead a QI initiative compared to those who answered incorrectly (p = 0.002). Most 0+5 residents report participation in a QI project during residency, however, few feel prepared to lead a QI initiative in practice. Furthermore, only half of PGY5 0+5 residents report achieving specific ACGME targets for graduation pertaining to QI. Current QI curricula in 0+5 programs may be inadequate in teaching fundamental QI concepts and achieving ACGME competency targets for graduation.

Enhancing communication and social engagement among clinicians and research teams to improve reliability of research recruitment

The success of rare disease research relies heavily on robust partnerships with clinicians to help identify new patients and collect samples. Many studies for paediatric rheumatic diseases requiring pretreatment samples...

Relationship of Necrotizing Enterocolitis Rates to Adoption of Prevention Practices in US Neonatal Intensive Care Units

Applying quality improvement methods has reduced necrotizing enterocolitis (NEC) in some neonatal intensive care units (NICUs) by 40% to 90%. This study was conducted to (1) examine relationships between adoption of prevention practices using the NEC-Zero adherence score and NEC rates, and (2) describe implementation strategies NICUs use to prevent NEC. A descriptive cross-sectional correlational study was completed among US quality improvement-focused NICUs. Relationships of the NEC-Zero adherence score to NEC rates were examined. Subgroup analyses explored relationships of a human milk adherence subscore and differences between high NEC rate (≥8%) and low NEC rate (≤2%) NICUs. NICUs (N = 76) ranged in size from 18 to 114 beds. The mean adherence score was 7.3 (standard deviation = 1.7; range, 3-10). The 10-point adherence score was not related to the NEC rate. The human milk subscore related to lower NEC rates (Rho = -0.26, P = .049), as was colostrum for oral care (Rho = -0.27, P = .032). The units that used a feeding protocol showed higher NEC rates (Rho = 0.27, P = .03), although very few addressed the use of effective implementation strategies to track adherence or to ensure consistency among clinicians. The units that used colostrum for oral care were more likely to adopt strategies to limit inappropriate antibiotic exposure (Rho = 0.34, P = .003). Broader use of evidence-based implementation strategies could bolster delivery of NEC prevention practices. Maternal lactation support is paramount. Future studies are needed to identify how individual clinicians deliver prevention practices, to find the extent to which this relates to overall delivery of prevention, and to study effects of bundles on NEC outcomes.

Improving long-lasting insecticidal nets use in Kayange community of north-western Burundi: a pilot study exploring the use of quality improvement methodologies in low-resource community settings

Quality improvement (QI) approaches have demonstrated a lot of promise in improving clinical care processes, both in high-resource and low-resource settings. However, most examples of QI initiatives in healthcare in...

Applying quality improvement strategies within Canadian population health promotion.

This article describes how quality improvement (QI) methodology was applied to partnership work in a population health promotion unit within a health care system. Using Kolb's experiential model of learning, we describe and reflect on our experience as a population health promotion unit working on a QI initiative focused on community partnerships for intersectoral collaboration. We identify contextual factors that can guide QI for population health promotion work. The three main lessons we identified were to (i) frame the need for improvement effectively, (ii) start by setting the conditions for others to lead and (iii) be people-focused as well as process-focused. Health care systems can apply QI methods to improve and strengthen their role in working with partners to improve population health. By sharing our experience with other practitioners, we hope to find support and allies as we learn together to improve quality in population health promotion settings.

Applying Quality Improvement Approaches to Reduce Mother-to-Child HIV Transmission and Improve Health and Nutrition Care in Five Countries: Lessons from the Partnership for HIV-Free Survival.

The World Health Organization guidelines for treating pregnant HIV-positive women and preventing HIV transmission to infants now recommend lifelong antiretroviral treatment for pregnant and breastfeeding women. We applied quality improvement (QI) methods to support governments and facility staff to address service gaps in 5 countries under the Partnership for HIV-Free Survival (PHFS). We used 3 key strategies: break the complex problem of improving HIV-free survival into more easily implementable phases, support a national management team to oversee the project, and support facility-level staff to learn and apply QI methods to reducing mother-to-child transmission. The key results in each country were increases in data completeness and accuracy, increases in retention in care of mother–baby pairs (MBPs), increase in coverage of MBPs with appropriate services, and reduction in vertical transmission of HIV. The PHFS experience offers a model that other multicountry networks can adopt to improve service delivery and quality of care.

Preparing The Critically Ill Adult Patient for Transfer

<p><strong>Background</strong></p><p>The reorganisation of hospital services in Ireland, the development of hospital groups, centralisation of specialties and reconfiguring of smaller hospitals necessitates inter hospital transfer of patients requiring specialist care to an appropriate hospital that meets their clinical needs. In Ireland, in excess of 1000 adult critical care inter hospital transfers occur per annum(1). The ‘hub-and-spoke’ model is aligned with the hospital group structure and connectivity between hospitals is provided through agreed transport and retrieval services. These transfers are generally undertaken by local teams (usually an anaesthetic NCHD and a nurse) using an emergency ambulance and crew. Multidisciplinary team training is provided, by Critical Care Retrieval Services, using local resources in a framework enhancing safety and preparedness.</p><p><strong>Aims </strong></p><p>A critical care transfer checklist with a systematic approach provides a framework to address the elements of critical care, transport physiology changes and reduce potential adverse events when transferring critically ill patients (2). The use of transport specific adjuncts and packaging the patient systematically not only addresses transport issues e.g. temperature, but also facilitates emergency interventions en route.</p><p><strong>Conclusion </strong></p><p>Patient safety is a fundamental principle in healthcare and is the responsibility of healthcare practitioners to apply quality improvement methods to effect process and system improvements. The use of a systematic approach to patient management when transporting critically ill patients establishes a higher level of performance reduces cognitive dissonance and provides a framework for clinical teams and reduces the potential for human error (3).</p><p> </p><p> </p>

Quality Child and Adolescent Psychiatry: Applying Quality Improvement Methods in Your Practice or Department

Quality Child and Adolescent Psychiatry: Applying Quality Improvement Methods in Your Practice or Department

Decreasing Stroke Code to CT Time in Patients Presenting with Stroke Symptoms.

Guided quality improvement (QI) programs present an effective means to streamline stroke code to computed tomography (CT) times in a comprehensive stroke center. Applying QI methods and a multidisciplinary team approach may decrease the stroke code to CT time in non-prenotified emergency department (ED) patients presenting with symptoms of stroke. The aim of this project was to decrease this time for non-prenotified stroke code patients from a baseline mean of 20 minutes to one less than 15 minutes during an 18-week period by applying QI methods in the context of a structured QI program. By reducing this time, it was expected that the door-to-CT time guideline of 25 minutes could be met more consistently. Through the structured QI program, we gained an understanding of the process that enabled us to effectively identify key drivers of performance to guide project interventions. As a result of these interventions, the stroke code to CT time for non-prenotified stroke code patients decreased to a mean of less than 14 minutes. This article reports these methods and results so that others can similarly improve the time it takes to perform nonenhanced CT studies in non-prenotified stroke code patients in the ED. ©RSNA, 2017.

Improving Hospital at Home for frail older people: insights from a quality improvement project to achieve change across regional health and social care sectors

BackgroundAgainst a background of rising numbers of frail older people, there is a need to improve quality and safety of services whilst containing costs. Improving patient outcomes requires change across hospital and community systems. Our objective was to change practice in order to deliver a Hospital at Home programme (admission avoidance and early supported discharge) for frail older people across a regional commissioning area. The programme, undertaken within the Northern, Eastern & Western Devon Clinical Commissioning Group (CCG) sub-localities of Exeter (population 120,000) and Woodbury, Exmouth and Budleigh Salterton (towns with populations of around 10,000), involved reconfiguration of existing services rather than being a stand-alone intervention.MethodsQuality Improvement methodology, with hospital and community staff using Plan-Do-Study-Act (PDSA) cycles to implement and test service changes. Outcome measures: 1) Discharge destination; 2) Length of stay; 3) Acute Community Team referrals.ResultsAgainst a backdrop of intense financial pressures, significant community bed closures, and difficult relations between hospital and community services, outcomes remained stable (discharge destination, length of hospital stay, and number of referrals to the community team).ConclusionPDSA cycles enabled stakeholders across acute and community services to be involved, promoted a process of collaborative inquiry and ownership of findings, and improved motivation to act on results and produce change. Practitioners and managers seeking to improve the delivery of complex, cross-cutting services in other areas can learn from the experience of applying Quality Improvement methods reported here.

Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital

ObjectivesReliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process...

Abstract 232: Postgraduate Education in Quality Improvement Methods: Initial Results of the Fellows’ Applied Quality Training Curriculum

Background: Formal training in quality improvement (QI) methods is sporadic in medical educational settings. QI is a growing expectation for individual professional certifications and facility accreditations; future physicians will need to understand and apply QI methods as part of their practice. We developed a curriculum with both didactic and applied components to teach QI methods to cardiology fellows. Methods: The Fellows Applied Quality Training (FAQT) curriculum started in July 2013 with an initial cohort of 23 postgraduate trainees in general and subspecialty cardiovascular medicine fellowships. The FAQT is a multifaceted QI curriculum consisting of online learning modules, didactic training, and the start-to-finish completion of a team-based, self-directed quality improvement project under supervision of a faculty mentor. Trainees completed selected modules from the Institute of Healthcare Improvement Open School including basic terminology and background of QI methods. Trainees were assigned to small groups and challenged to identify an area in need, design an intervention to improve quality or safety, select an appropriate metric to measure, determine how to acquire the necessary data, implement their plan, analyze data to measure their success, and formally present the results. Prior to, during, and at the completion of the FAQT, trainees completed the 13 question self-assessment from the Quality Assessment and Improvement Curriculum. This assessment asks participants to rate their confidence to perform QI activities independently. The primary outcome of our investigation was an increase in the median confidence score reported on a 4 point scale (1=not at all confident, 2=slightly confident, 3=moderately confident, 4=extremely confident) compared by Wilcoxon signed rank test. Results: Prior to the FAQT, 15 trainees reported no prior formal QI training. Of those with prior training, 4 were practical and 4 had only didactic training. At baseline, the median score given on the assessment was 3.0. After completion of online training modules, the median score did not increase (3.0, p=0.51). At the conclusion of the self-directed projects, average confidence was higher (3.27, p=0.004). The proportion of fellows reporting they were “extremely” confident about using quality assessment and improvement in your future career increased from15% to 50% while the proportion reporting “slight” confidence decreased from 30% to 5%. Conclusion: At our institution, the majority of post-graduate medical trainees had no formal exposure to QI training. After completing a curriculum with practical application of QI methods, trainees reported an increase in their self-confidence to independently conduct QI; no increase was observed with didactic training alone.

A case study: Applying quality improvement methods to reduce pre-operative length of stay in a resource-constrained setting in Rwanda

Objective: While several studies have focused on improving the quality of surgery, less attention has been paid to reducing pre-operative delays in care. We undertook a hospital quality improvement (QI) effort to reduce pre-operative delays in a teaching hospital in Rwanda. Without a coordinated admission schedule, many surgical patients arriving at the hospital for admissions were turned away because of unavailable beds. For those admitted for surgery, the pre-operative waits were long.Methods: A pre- and post-intervention study was conducted to examine the impact of a QI effort on two metrics: 1) pre-operative length-of-stay (LOS) for elective surgical patients, and 2) the number of elective surgical patients who were turned away on the scheduled admission date. Intervention: A multi-disciplinary work group utilized a Strategic Problem Solving Approach and implemented a centralized patient wait list and new schedule process utilizing the existing resources available at the hospital.Results: The percentage of elective surgical patients with a pre-operative LOS of more than two days was significantly lower in the post-intervention compared with the pre-intervention period (80% versus 26.8%, p-value < .001). The percentage of scheduled patients who were turned away due unavailable inpatient beds significantly decreased from 63.4% to 5.3%, p-value < .001.Conclusions: By following a methodical strategic problem solving approach, the pre-operative LOS was reduced, elective surgical patients turned away due to unavailable beds was decreased at very low financial cost.

Improving Nonattendance at Outpatient Pediatric Endoscopy Unit of a Tertiary Center.

Failure to attend pediatric outpatient endoscopic procedures leads to inefficient use of resources, longer wait-list times, and delay in diagnoses. The causes for pediatric endoscopy nonattendance are not well studied. The aim of the study was to identify factors associated with failure to attend endoscopic procedures and to assess the value of quality improvement (QI) interventions implemented to improve pediatric endoscopy attendance. This was a continuous QI project. We collected nonattendance data from November 2011 to November 2013. Information collected included procedure type, age, sex, time on the waiting list, history of previous procedures, and reason for nonattendance. The following QI interventions were implemented sequentially: an appointment reminder letter, a telephone call 1 week before procedure, and creation of an electronic medical note dedicated to endoscopy appointment. Pareto charts and statistical process control charts were used for analysis. From November 2011 to November 2013, we were able to decrease nonattendance from 17% to 11% (P = 0.005). No-show rate was reduced from 5% to 0.9% (P = 0.00001). There was no significant difference between attendees and nonattendees in relation to sex, age, or having a previous procedure. Longer waiting time (33 vs 26 days) was associated with increased risk for nonattendance (P = 0.0007). The most common causes for nonattendance were illness (31.5%), followed by caregiver/patients who no longer wanted the procedure (17.7%), and patients who improved (12.9%). Applying QI methods and tools improved pediatric endoscopy attendance. Longer wait time for endoscopic procedures is associated with nonattendance. Given the increased pediatric endoscopy demand, strategies should be implemented to reduce wait time for pediatric endoscopy.