Continuous Quality Improvement Program Research Articles

Substantial Progress Yet Significant Opportunity for Improvement in Stroke Care in China

Stroke is a leading cause of death in China. Yet the adherence to guideline-recommended ischemic stroke performance metrics in the past decade has been previously shown to be suboptimal. Since then, several nationwide stroke quality management initiatives have been conducted in China. We sought to determine whether adherence had improved since then. Data were obtained from the 2 phases of China National Stroke Registries, which included 131 hospitals (12 173 patients with acute ischemic stroke) in China National Stroke Registries phase 1 from 2007 to 2008 versus 219 hospitals (19 604 patients) in China National Stroke Registries phase 2 from 2012 to 2013. Multiple regression models were developed to evaluate the difference in adherence to performance measure between the 2 study periods. The overall quality of care has improved over time, as reflected by the higher composite score of 0.76 in 2012 to 2013 versus 0.63 in 2007 to 2008. Nine of 13 individual performance metrics improved. However, there were no significant improvements in the rates of intravenous thrombolytic therapy and anticoagulation for atrial fibrillation. After multivariate analysis, there remained a significant 1.17-fold (95% confidence interval, 1.14-1.21) increase in the odds of delivering evidence-based performance metrics in the more recent time periods versus older data. The performance metrics with the most significantly increased odds included stroke education, dysphagia screening, smoking cessation, and antithrombotics at discharge. Adherence to stroke performance metrics has increased over time, but significant opportunities remain for further improvement. Continuous stroke quality improvement program should be developed as a national priority in China.

Economic Impact of a Peritoneal Dialysis Continuous Quality Improvement Program in Colombia.

♦ BACKGROUND: There is little information regarding the financial burden of peritonitis and the economic impact of continuous quality improvement (CQI) programs in peritoneal dialysis (PD) patients. The objectives of this study were to measure the costs of peritonitis, and determine the net savings of a PD CQI program in Colombia. ♦ METHODS: The Renal Therapy Services (RTS) network in Colombia, along with Coomeva EPS, provided healthcare resource utilization data for PD patients with and without peritonitis between January 2012 and December 2013. Propensity score matching and regression analysis were performed to estimate the incremental cost of peritonitis. Patient months at risk, episodes of peritonitis pre- and post-CQI, and costs of CQI were obtained. Annual net savings of the CQI program were estimated based on the number of peritonitis events prevented. ♦ RESULTS: The incremental cost of a peritonitis episode was $250. In an 8-year period, peritonitis decreased from 1,837 episodes per 38,596 patient-months in 2006 to 841 episodes per 50,910 patient-months in 2014. Overall, the CQI program prevented an estimated 10,409 episodes of peritonitis. The cost of implementing the CQI program was $147,000 in the first year and $119,000 annually thereafter. Using a five percent discount rate, the net present value of the program was $1,346,431, with an average annual net savings of $207,027. The return on investment (i.e. total savings-program cost/program cost) of CQI was 169%. ♦ CONCLUSION: Continuous quality improvement initiatives designed to reduce rates of peritonitis have a strong potential to generate cost savings.

Truth or dare: Achieving lower radiation doses in CT

The continuous evolution of computed tomography (CT) technology has allowed for wider clinical CT utilization. However the increased radiation doses associated with CT have raised concerns about the risk of carcinogenesis among Radiation Protection Authorities, health professionals and patients. Although the benefit of a justified CT examination by and large outweighs the risk, optimization of the procedure is essential to further this risk. Moreover CT manufacturers have developed several dose reduction tools and dose alert platforms to modulate and record the radiation doses administered to patients. The scope of this presentation is to outline the significance of optimization in CT, to describe CT parameters, scanner dose output indices and the methodology to reduce dose without compromising diagnostic quality. Learning Outcomes: Following the presentation, participants will be able to: 1. Demonstrate the difference between CT scanner output and effective dose. 2. Fine-tune dose reduction parameters ensuring ALARA and according to clinical requirements (i.e. mAs and kV modulation, section collimation, detector array selection, pitch). 3. Distinguish between noise reduction iterative reconstruction algorithms and dose. 4. Correlate CT dose indices to national DRLs. 5. Participate in CT protocol design and continuous quality improvement programs. 6. Promote Radiation Protection Campaigns (i.e. Image Wisely, Image Gently, Eurosafe Imaging, RPOP). No disclosures.

NAP SACC: Implementation of an Obesity Prevention Intervention in an American Indian Head Start Program

ABSTRACTLow-income American Indian preschoolers are at greatest risk for overweight and obesity among children aged 2–5 years. The Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) program is an evidence-based intervention that promotes healthy weight development for children enrolled in child care centers. The goal of this continuous quality improvement program is for the child care staff to establish environmental policies and practices that positively influence nutrition and physical activity-related behaviors. A community needs assessment of a Head Start program on an American Indian reservation identified obesity as a priority issue. This project implemented NAP SACC at 15 Head Start sites on the reservation.

Wide Variation in Absolute Cardiovascular Risk Assessment in Aboriginal and Torres Strait Islander People with Type 2 Diabetes.

Absolute cardiovascular risk assessment (CVRA) is based on the combined effects of multiple risk factors and can identify asymptomatic individuals at high risk of cardiovascular disease (CVD). Aboriginal and Torres Strait Islander people, the Indigenous people of Australia, are disproportionately affected by CVD and diabetes. Our study aimed to investigate variations in the use of absolute CVRA in patients with diabetes at Indigenous community healthcare centers and to identify patient and health center characteristics that may contribute to this variation. Audits of clinical records of 1,728 patients with a known diagnosis of diabetes across 121 health centers in four Australian States/Territories [Northern Territory (NT), South Australia, Western Australia, and Queensland] over the period 2012-2014 were conducted as part of a large-scale continuous quality improvement program. Multilevel regression modeling was used to quantify variation in recording of CVRA attributable to health center and patient characteristics. The proportion of eligible patients with documented CVRA was 33% (n = 574/1,728). The majority (95%) of assessments were conducted in the NT. Multilevel regression analysis showed health center characteristics accounted for 70% of the variation in assessments in the NT. Government-operated health centers had 18.8 times the odds (95% CI 7.7-46.2) of recording CVRA delivery compared with other health centers. Health centers in the NT delivered the majority of absolute CVRA to Indigenous patients with diabetes in our study. Health systems factors that may have facilitated provision of CVRA in the NT include decision support tools and a reporting process for CVRA delivery. Implementation of similar systems in other jurisdictions may help improve CVRA delivery. Early identification and treatment of high risk individuals through wider use of CVRA may help reduce the burden of CVD in Indigenous Australians with diabetes.

Implementing a Continuous Quality Improvement Program in a High-Volume Clinical Echocardiography Laboratory

Background— The management of aortic stenosis rests on accurate echocardiographic diagnosis. Hence, it was chosen as a test case to examine the utility of continuous quality improvement (CQI) approaches to increase echocardiographic data accuracy and reliability. A novel, multistep CQI program was designed and prospectively used to investigate whether it could minimize the difference in aortic valve mean gradients reported by echocardiography when compared with cardiac catheterization. Methods and Results— The Duke Echo Laboratory compiled a multidisciplinary CQI team including 4 senior sonographers and MD faculty to develop a mapped CQI process that incorporated Intersocietal Accreditation Commission standards. Quarterly, the CQI team reviewed all moderate- or greater-severity aortic stenosis echocardiography studies with concomitant catheterization data, and deidentified individual and group results were shared at meetings attended by cardiologists and sonographers. After review of 2011 data, the CQI team proposed specific amendments implemented over 2012: the use of nontraditional imaging and Doppler windows as well as evaluation of aortic gradients by a second sonographer. The primary outcome measure was agreement between catheterization- and echocardiography-derived mean gradients calculated by using the coverage probability index with a prespecified acceptable echocardiography–catheterization difference of <10 mm Hg in mean gradient. Between January 2011 and January 2014, 2093 echocardiograms reported moderate or greater aortic stenosis. Among cases with available catheterization data pre- and post-CQI, the coverage probability index increased from 54% to 70% ( P =0.03; 98 cases, year 2011; 70 cases, year 2013). The proportion of patients referred for invasive valve hemodynamics decreased from 47% pre-CQI to 19% post-CQI ( P <0.001). Conclusions— A laboratory practice pattern that was amenable to reform was identified, and a multistep modification was designed and implemented that produced clinically valuable performance improvements. The new protocol improved aortic stenosis mean gradient agreement between echocardiography and catheterization and was associated with a measurable decrease in referrals of patients for invasive studies.

End-of-life care pathways for improving outcomes in caring for the dying.

This is an updated version of a Cochrane review published in Issue 11, 2013 in the Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time, and that it is provided by the most appropriate health professional. Since the last update, there have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the United Kingdom (UK). Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways via a systematic review. To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying, or those related to the care, such as families, carers and health professionals, or a combination of these. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library; 2015, Issue 6), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles, trial registries and reference lists of relevant articles. We conducted the original search in September 2009, and the second updated search in July 2015. All randomised controlled trials (RCTs), quasi-randomised trials or high quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying. Two review authors independently assessed the results of the searches against the predetermined criteria for inclusion, assessed risk of bias, and extracted data. We used standard methodological procedures expected by Cochrane. We screened 3028 titles, and included one Italian cluster RCT with 16 general medicine wards (inpatient units in hospitals) and 232 carers of cancer patients in this updated review. We judged the study to be at a high risk of bias overall, mainly due to a lack of blinding and rates of attrition. Only 34% of the participants (range 14% to 75% on individual wards) were cared for in accordance with the care pathway as planned. However, these issues were to be expected due to the nature of the intervention and condition. The study population was all cancer patients in their last days of life. Participants were allocated to care using the Liverpool Care Pathway (LCP-I, Italian version of a continuous quality improvement programme of end-of-life care) or to standard care. The primary outcomes of this review were physical symptom severity, psychological symptom severity, quality of life, and any adverse effects. Physical symptom severity was assessed as overall control of pain, breathlessness, and nausea and vomiting. There was very low quality evidence of a difference in overall control of breathlessness that favoured the Liverpool Care Pathway group compared to usual care: the study reported an odds ratio (OR) of 2.0 with 95% confidence intervals (CIs) 1.1 to 3.8. Very low quality evidence of no difference was found for pain (OR 1.3, 95% CI 0.7 to 2.6, P = 0.461) and nausea and vomiting (OR 1.5, 95% CI 0.7 to 3.2, P = 0.252). None of the other primary outcomes were assessed by the study. Limited data on advance care planning were collected by the study authors, making results for this secondary outcome unreliable. None of our other secondary outcomes were assessed by the study. There is limited available evidence concerning the clinical, physical, psychological or emotional effectiveness of end-of-life care pathways.

Abstract TP330: Substantial Progress yet Significant Opportunity for Improvement in Stroke Care in China

Background: Stroke is a leading cause of death in China. Yet the adherence to guideline-recommended stroke performance metrics was suboptimal in the past decade. We sought to determine whether adherence changed after the implementation of the China National Quality Management Initiatives. Methods and Results: Data were obtained from the China National Stroke Registries (CNSR), and included 132 hospitals (12 173 patients) participated in CNSR Phase I (2007-2008) vs. 219 hospitals (19 604 patients) in CNSR Phase II (2012-2013). The overall adherence increased over time, as reflected by the higher composite score of 0.76 in 2012-2013 as compared with 0.63 in 2007-2008, and the increase in 9 of 13 individual metrics, including dysphagia screening, carotid imaging, rehabilitation evaluation, antithrombotics, lipid-lowering, antihypertensive medications, antidiabetic medications at discharge, smoking cessation, and stroke education). However, there were no significant improvements in the intravenous thrombolytic therapy, early antithrombotics, deep vein thrombosis prophylaxis, and anticoagulation for atrial fibrillation. Multivariate analysis suggested that there was a 1.17-fold increase in the odds of fulfilling care opportunities. Conclusions: Adherence to stroke performance metrics increased recently, but significant opportunities remain for further improvement. Continuous stroke quality improvement program should be developed as a national priority in China.

Implementing quality improvement programs for colonoscopy: the emerging need for an international, standardized, multidisciplinary approach.

Implementing quality improvement programs for colonoscopy: the emerging need for an international, standardized, multidisciplinary approach.

Continuous quality improvement programs—part i: survey, critical analysis and future research directions

In practice, the diversity of management philosophies, quality programs, and quality tools has resulted in many quality consulting firms to be established most often offering the same product under a different packaging. This continual repackaging of quality programs for marketing purposes has led to confusion and resulted in organizations often abandoning a specific quality program in favor of another, although programs could be complementary in nature. In an attempt to assist organizations in making informed decisions with respect to the choice of continuous quality improvement programs (CQIPs), we survey and critically analyze the landscape of research on CQIPs, highlight similarities and differences between the underlying quality philosophies, and discuss the limitations of the current generic designs of CQIPs; namely, Just-in-Time (JIT), Benchmarking, Kaizen, International Organization for Standardization (ISO), Business Process Reengineering (BPR), and Six Sigma. Our analysis of the literature revealed that, with the exception of Six Sigma, most published design and implementation procedures of CQIPs ignore a problem definition phase, most programs ignore performance measurement and evaluation as a formal phase along with the specification of the relevant criteria according to which performance is to be assessed, most programs lack the explicit integration of auditing, monitoring, control and feedback mechanisms, most published research on quality programs tend either to ignore the explicit integration of quality tools or to refer to a very limited number of potential tools without any guidelines as to which phases they could be used at, most continuous quality improvement programs lack a theoretical grounding in management theories as well as conceptual models, and no published research formally integrates critical success factors into the design methodology of a quality program. In this paper, we attempt to address this last methodological problem by proposing a classification of critical factors of CQIPs that could be used to assist managers in designing and customizing specific programs to their specific environments. In addition, we discuss the potential benefits of hybridization of quality philosophies and programs whereby several quality philosophies, concepts, programs, and tools are coherently integrated into a hybrid CQIP for the purpose of improving quality and reducing waste. Finally, we outline some future research directions.

Identifying discharge process factors causing an increased length of stay

Introduction: The purpose of continuous quality improvement programs is to improve health care by identifying problems, implementing and monitoring corrective action, and studying its effectiveness. Aim: The present study aims to find out the present length of stay (LOS) of inpatients at a superspeciality hospital. Objectives: 1. To study the existing system of discharge process of patients, 2. to find out the reasons for the delays, 3. To recommend suitable suggestions to reduce length of stay. Mehodology and Results: By considering the LOS of 128 random patients, 32 from each ward A, B, C, and D. The average LOS (ALOS) was found to be 5.69. Factors have been identified by studying the delays through time and motion study in the discharge process. Recommendations: Recommendations have been made for appropriate changes to be considered to reduce ALOS and bring it to 5.0 so that proper resource utilization occurs, and at the same time, there is an improvement in bed turnover rate and thereby in bed occupancy rates.

Furthering the quality agenda in Aboriginal community controlled health services: understanding the relationship between accreditation, continuous quality improvement and national key performance indicator reporting.

A rapidly expanding interest in quality in the Aboriginal-community-controlled health sector has led to widespread uptake of accreditation using more than one set of standards, a proliferation of continuous quality improvement programs and the introduction of key performance indicators. As yet, there has been no overarching logic that shows how they relate to each other, with consequent confusion within and outside the sector. We map the three approaches to the Framework for Performance Assessment in Primary Health Care, demonstrating their key differences and complementarity. There needs to be greater attention in both policy and practice to the purposes and alignment of the three approaches if they are to embed a system-wide focus that supports quality improvement at the service level.

Barriers and facilitators to implementing continuous quality improvement programs in colonoscopy services: a mixed methods systematic review.

Background and aim: Continuous quality improvement (CQI) programs may result in quality of care and outcome improvement. However, the implementation of such programs has proven to be very challenging. This mixed methods systematic review identifies barriers and facilitators pertaining to the implementation of CQI programs in colonoscopy services and how they relate to endoscopists, nurses, managers, and patients. Methods: We developed a search strategy adapted to 15 databases. Studies had to report on the implementation of a CQI intervention and identified barriers or facilitators relating to any of the four groups of actors directly concerned by the provision of colonoscopies. The quality of the selected studies was assessed and findings were extracted, categorized, and synthesized using a generic extraction grid customized through an iterative process. Results: We extracted 99 findings from the 15 selected publications. Although involving all actors is the most cited factor, the literature mainly focuses on the facilitators and barriers associated with the endoscopists’ perspective. The most reported facilitators to CQI implementation are perception of feasibility, adoption of a formative approach, training and education, confidentiality, and assessing a limited number of quality indicators. Receptive attitudes, a sense of ownership and perceptions of positive impacts also facilitate the implementation. Finally, an organizational environment conducive to quality improvement has to be inclusive of all user groups, explicitly supportive, and provide appropriate resources. Conclusion: Our findings corroborate the current models of adoption of innovations. However, a significant knowledge gap remains with respect to barriers and facilitators pertaining to nurses, patients, and managers.

SCAI core curriculum for adult and pediatric interventional fellowship training in continuous quality assessment and improvement.

Keywords: percutaneous coronary intervention; structural heart disease intervention; congential heart disease; adults; congenital heart disease; pediatrics

Using Surgeon-Specific Outcome Reports and Positive Deviance for Continuous Quality Improvement

Using the thoracic morbidity and mortality classification to document all postoperative adverse events between October 2012 and February 2014, we created surgeon-specific outcome reports (SSORs) to promote self-assessment and to implement a divisional continuous quality improvement (CQI) program, on the construct of positive deviance, to improve individual surgeon's clinical performance. Mixed-methods study within a division of six thoracic surgeons, involving (1) development of real-time, Web-based, risk-adjusted SSORs; (2) implementation of CQI seminars (n= 6; September 2013 to June 2014) for evaluation of results, collegial discussion on quality improvement based on identification of positive outliers, and selection of quality indicators for future discussion; and (3) in-person interviews to identify facilitators and barriers to using SSORs and CQI. Interview transcripts were analyzed using thematic analysis. Interviews revealed enthusiastic support for SSORs as a means to improve patient care through awareness of personal outcomes with blinded divisional comparison for similar operations and diseases, and apply the learning objectives to continuous professional development and maintenance of certification. Perceived limitations of SSORs included difficulty measuring surgeon expertise, limited understanding of risk adjustment, resistance to change, and belief that knowledge of sensitive data could lead to punitive actions. All surgeons believed CQI seminars led to collegial discussions, whereas perceived limitations included quorum participation and failing to circle back on actionable items. Real-time performance feedback using SSORs can motivate surgeons to improve their practice, and CQI seminars offer the opportunity to review and interpret results and address issues in a supportive environment. Whether SSORs and CQI can lead to improvements in rates of postoperative adverse events is a matter of ongoing research.

Challenges in Hospital-Associated Infection Management

Maintaining a successful unit-based continuous quality improvement program for managing hospital-associated infections is a huge challenge and an overwhelming task. It requires strong organizational support and unit leadership, human and fiscal resources, time, and a dedicated and motivated nursing staff. A great deal of effort goes into implementing, monitoring, reporting, and evaluating quality improvement initiatives and can lead to significant frustration on the part of the leadership team and nursing staff when quality improvement efforts fail to produce the desired results. Each initiative presents its own unique set of challenges; however, common issues influence all initiatives. These common issues include organization and unit culture, current clinical practice guidelines being used to drive the initiatives, performance discrepancies on the part of nursing staff, availability of resources including equipment and supplies, monitoring of the data, and conflicting quality improvement priorities.

The association between event learning and continuous quality improvement programs and culture of patient safety

PurposeTo present our approach and results from our quality and safety program and to report their possible impact on our culture of patient safety. Methods and materialsWe created an event learning system (termed a “good catch” program) and encouraged staff to report any quality or safety concerns in real time. Events were analyzed to assess the utility of safety barriers. A formal continuous quality improvement program was created to address these reported events and make improvements. Data on perceptions of the culture of patient safety were collected using the Agency for Health Care Research and Quality survey administered before, during, and after the initiatives. ResultsOf 560 good catches reported, 367 could be ascribed to a specific step on our process map. The calculated utility of safety barriers was highest for those embedded into the pretreatment quality assurance checks performed by physicists and dosimetrists (utility score 0.53; 93 of 174) and routine checks done by therapists on the initial day of therapy. Therapists and physicists reported the highest number of good catches (24% each). Sixty-four percent of events were caused by performance issues (eg, not following standardized processes, including suboptimal communications). Of 31 initiated formal improvement events, 26 were successfully implemented and sustained, 4 were discontinued, and 1 was not implemented. Most of the continuous quality improvement program was conducted by nurses (14) and therapists (7). Percentages of positive responses in the patient safety culture survey appear to have increased on all dimensions (p < .05). ConclusionsResults suggest that event learning and continuous quality improvement programs can be successfully implemented and that there are contemporaneous improvements in the culture of safety.

Bowel Preparation, Colonoscopy Withdrawal Time and Adenoma Detection Rate: A Prospective Study of Screening Colonoscopies

There are few studies on the determinants of poor bowel preparation among colorectal cancer screening participants, and current evidence on the association between bowel preparation and adenoma detection was inconclusive. We evaluated the independent factors associated with poor bowel preparation and its impact on adenoma detection. We included asymptomatic subjects aged between 50-70 years who self-referred for colorectal cancer screening and received colonoscopy between 2008 and 2012 in Hong Kong. The quality of the bowel preparation was assessed by colonoscopists, and the factors associated with poor bowel cleansing were evaluated by binary logistic regression analyses. A multivariate regression model was constructed to evaluate if poor bowel preparation was associated with detection of colorectal neoplasia. From 5,470 screening participants with an average age of 57.7 years (SD 4.9), up to 34.6% had poor or fair bowel preparation. The level of poor or fair bowel preparation was as high as 34.6%. After controlling for sociodemographic and clinical factors, older age (≥ 60 years; adjusted odds ratio [AOR]=1.19 to 1.38, P = .017-0.038), male gender (AOR=1.38, 95% C.I. 1.19-1.60, P < .001), and smokers (AOR=1.41, 95% C.I. 1.14-1.75, P = .002) were significantly associated with poor or fair bowel preparation. Poorer cleansing led to longer caecal intubation time and colonoscopy withdrawal time, yet resulted in significantly lower detection rates of colorectal neoplasia (AOR=0.35 to 0.62) and colorectal advanced neoplasia (AOR=0.39 to 0.50) irrespective of their diameter (< 5mm or ≥ 5mm). Steps to improve proper procedures of bowel preparation are warranted, especially among subjects at risk of poor bowel preparation. These include more intensive preparation protocols and measures to improve patient understanding of bowel preparation as parts of continuous quality-improvement programmes. This study supports bowel preparation as a definite quality indicator.

Study of continuous quality improvement for clinical laboratory processes via the platform of Hospital Group

The program of continuous quality improvement in clinical laboratory processes for complete blood count (CBC) was launched via the platform of Beijing Children's Hospital Group in order to improve the quality of pediatric clinical laboratories. Fifteen children's hospitals of Beijing Children's Hospital group were investigated using the method of Chinese adapted continuous quality improvement with PDCA (Plan-Do-Check-Action). The questionnaire survey and inter-laboratory comparison was conducted to find the existing problems, to analyze reasons, to set forth quality targets and to put them into practice. Then, targeted training was conducted to 15 children's hospitals and the second questionnaire survey, self examinations by the clinical laboratories was performed. At the same time, the Group's online internal quality control platform was established. Overall effects of the program were evaluated so that lay a foundation for the next stage of PDCA. Both quality of control system documents and CBC internal quality control scheme for all of clinical laboratories were improved through this program. In addition, standardization of performance verification was also improved, especially with the comparable verification rate of precision and internal laboratory results up to 100%. In terms of instrument calibration and mandatory diagnostic rates, only three out of the 15 hospitals (20%) failed to pass muster in 2014 from 46.67% (seven out of the 15 hospitals) in 2013. The abnormal data of intraday precision variance coefficients of the five CBC indicator parameters (WBC, RBC, Hb, Plt and Hct) of all the 15 laboratories accounted for 1.2% (2/165) in 2014, a marked decrease from 9.6% (14/145) in 2013. While the number of the hospitals using only one horizontal quality control object for daily quality control has dropped to three from five. The 15 hospitals organized a total of 263 times of training in 2014 from 101 times in 2013, up 160%. The quality improvement program for the clinical laboratories launched via the Hospital Group platform can promote the joint development of the pediatric clinical laboratory discipline of all the member hospitals with remarkable improvement results, and the experience is recommendable for further rollout.

Improving compliance with central venous catheter care bundles using electronic records.

Health care associated infections are a major contributor to avoidable harm experienced by patients in modern health care settings. Recent reports suggest that electronic checklists for the documentation of a central line bundle may significantly enhance documented process compliance and help to reduce catheter-related bloodstream infection rates. This paper describes the use of our electronic tool to monitor and feedback process compliance in conjunction of introducing bespoke central line insertion packs to tackle catheter-related bloodstream infections in our intensive care unit in a medium-sized district general hospital. Continuous quality improvement programme with 'Plan-Do-Study-Act' cycles was implemented. The central venous catheter insertion and maintenance bundle was rolled out in 2007. To monitor compliance with the bundle elements, an electronic tool was designed as part of our bedside Clinical Information System. From 2009, regular quarterly feedback was provided on the number of central venous catheter lines inserted, compliance with the insertion and maintenance bundle and catheter-related bloodstream infection rate using the data collected through the Clinical Information System. We have also introduced dedicated line insertion trolleys and factory-prepared insertion packs. We used segmented regression analysis to assess the changes in the catheter-related bloodstream infection rate before and after implementation of the central venous catheter bundle. Bundle compliance increased during the implementation period and reached over 95% within 6 months. We observed a significant reduction in the catheter-related bloodstream infection rate from 15.6/1000 days to 0.4/1000 days. Regression analysis showed that only the compliance had significant effect on the number and prevalence of catheter-related bloodstream infections. Implementation of evidence-based care bundles reinforced by real-time feedback on the performance of caregivers can significantly reduce the rate of catheter-related bloodstream infection in the intensive care unit. Ensuring that change processes are seamlessly integrated in the workflow with minimal administrative burden is crucial to the quality improvement process.