Continuous Quality Assessment Research Articles

Quality assessment of endoscopic retrograde cholangiopancreatography

Endoscopic retrograde cholangiopancreatography (ERCP) has a high risk of various complications. The aim of this study is to report the main ERCP outcome, that means complications and success rates, on the basis of the pooled data of a national continuous quality assessment program. This study is an uncontrolled prospective survey and provides data from both academic and community-based endoscopy centers with varying case volumes and expertise. Data were collected within a nationwide voluntary ERCP benchmarking project that was initiated by the Austrian Society of Gastroenterology and Hepatology. In total, 42 sites participated in this program for varying periods (1 month up to 5 years) and reported 13 513 procedures within 5 years. The overall complication rate in nonselected patients was 10.1%. Post-ERCP pancreatitis occurred in 4.2%, bleeding in 3.6% (0.4% clinically relevant), cholangitis in 1.4%, cardiopulmonary complications in 1.2%, perforation in 0.6%, and procedure-related deaths in 0.1% of procedures. The overall therapeutic and diagnostic target was achieved in 80.3% (2009-2011) to 84.8% (2006/2007) of procedures. The desired duct was visualized in 90.7% and cannulated in 88.8% of procedures. The aim of the running benchmarking project in ERCP is to improve patient care in Austria. The survey reflects the general effectiveness and safety of ERCP. The overall complication and success rates are consistent with the available literature data. It sets an example as a benchmarking program that might result in international or even pan-European projects in high-risk endoscopic procedures.

Using information technology to improve cancer care.

322 Background: Since 1996, the U.S. federal government has passed several laws aimed at improving the health care system, specifically health care quality, safety, and efficiency. Among these laws is the Health Information Technology for Economic and Clinical Health (HITECH) Act, enacted as part of the American Recovery and Reinvestment Act of 2009, which mandates the adoption and meaningful use of information technology (IT) for clinical purposes. The HITECH Act further defines meaningful use objectives as Improving Quality, Safety, Efficiency; Engaging Patients and Families; Improving Care Coordination; Improving Public and Population Health; Ensuring Privacy and Security for Personal Health Information. To meet the adoption requirement, the University of New Mexico Hospital system implemented Powerchart by Cerner in 1999. In addition, the UNM Cancer Center (UNMCC) implemented MOSAIQ by Elektra in 2010. Both meet Meaningful Use requirements. This abstract describes how UNMCC improves clinical quality with these two IT systems. Methods: UNMCC uses Powerchart to capture patient data such as charting, medications and test results. MOSAIQ is used to manage the patients therapy orders. Because these IT systems capture all patient data and treatment plans, clinic physicians have access to all the information when making treatment decisions either in the clinic or in the hospital. Additionally, UNMCC uses continuous quality assessments to design appropriate clinical process interventions and to document safety and accuracy improvements in patient care. Results: In the 18 months since implementing both IT systems and continuous assessments, UNMCC can demonstrate the following improvements in quality of patient care: Fewer clinic errors in ordering lab tests, dispensing medication, billing, and modifying chemotherapy doses; Improved authorization processes with insurance providers, resulting in more timely consultations with patients; Optimization of molecular tests ordered and performed, resulting in cost savings; Reductions in staff and overhead. Conclusions: By using IT as part of its clinical quality systems, UNMCC has achieved overall improvements in patient care.

A Study on Adaptability of Total Quality Management in Engineering Education Sector

Quality management is an approach to management which requires establishing quality policies, procedures and practices on regular basis. Engineering education is a process of developing techno human resources, which are to be used later as input to industry which in turn produces goods and services for the societal use. Having considered the current situation of the engineering educational system and the quality of all its individual components it can be noticed that the awareness of the importance of education as a foundation for the growth and development of the country, such as India, is not strong enough. Engineering graduates passing out from educational institutions have to fulfill modern and high standard requirements that are needed by industry. Therefore, there is a greater need to instill quality in engineering education to produce technically skilled and creative man-power in India. The continuous assessment of quality is of paramount importance for educational institution. Education efficiency and success does not depend just on quantity but as well on quality. This paper has discussed key points for the improvement in the quality of engineering education with a case study undertaken at various engineering colleges in India. The study was conducted in two phase; first phase is the critical investigation of the literature and the second phase is a study on the quality of engineering education provided by the educational institutions in Visakhapatnam city. A simple random sampling technique was adopted for the study. A research study described in this paper identifies and analyses the quality of engineering education at the educational institutions which adopt the total quality management system to increase the quality and meet the industrial requirements and then suggests some ingredients to improve the quality.

Feasibility study of a simple IAQ index for assessing air‐conditioned offices

PurposeIt is costly to sample all air pollutants of a general community for continuous indoor air quality (IAQ) assessments. To optimize the resources for IAQ baseline monitoring for general facilities management, this study aims to investigate the feasibility of using a simple IAQ index as a screening parameter of a screening test to identify an asymptomatic air‐conditioned office with probable unsatisfactory IAQ.Design/methodology/approachThe IAQ index is determined from the fractional dose of some representative common indoor air pollutants of unsatisfactory IAQ, either by taking equal importance of the pollutants as a weighting factor or weighted by the regional failure rates with respect to the corresponding air pollutants. Specifically, a database of regional IAQ assessment results of 422 air‐conditioned offices was employed to justify the selected screening levels for the IAQ index.FindingsThe proposed IAQ index of a screening assessment was used for verifying, respectively, 58 and seven air‐conditioned offices of Hong Kong with satisfactory and unsatisfactory IAQ. The results showed that 57 satisfactory offices and two unsatisfactory offices were correctly identified by the unweighted and weighted IAQ indices respectively. Evaluation of the proposed index in further IAQ improvements of some offices showed that it would be a practical tool for preliminary IAQ screening assessment.Research limitations/implicationsThe screening test itself could not identify all the IAQ problems but could identify the office groups with higher risk of unsatisfactory IAQ with reduced effort.Practical implicationsThe study shows the usefulness of the proposed IAQ index to identify the unrecognized IAQ problems for air‐conditioned office environments. It could be adopted as a routine screening measure in facility management of which a wide‐ranging set of IAQ measurement is undesired.Originality/valueThis study presents a useful reference for policymakers, building owners and professionals for indoor environmental assessments.

A study to explore internal auditors’ compliance with Quality Assurance Standards: A case of state owned corporations in Kenya

The Internal Audit Department in any organization (including State Owned Corporations) has a role of assisting the management in achieving their objectives and adding value to organizational operations by evaluating and improving the effective of risk management, internal controls and governance processes. To achieve this, the Internal Audit Department is required by the Institute of Internal Auditors (IIA) to carry out a continuous internal quality assessment and an external assessment at least once in five years. The literature suggests that internal auditors in Africa including Kenya do not comply with the quality assurance standards as set by the IIA. This research collected data from 24 Internal Audit Units from State Owned Corporations regarding their compliance with quality assurance standards. The research carried out a hypothesis testing using the data collected to find out whether the audit departments in state owned corporations comply with quality assurance standards. The study found out that there is generally low compliance with quality assurance standards among most internal audit units in state owned corporations in Kenya. The research identified some of the reasons that led to low compliance to include; lack of awareness of standards; non-membership with IIA; non adoption of IPPF; age and experience of the internal audit department and understanding of the quality assurance standards.

Dynamic data maintenance for quality data, quality research

Just like any other scientific research field, the value of data quality is undisputed in the field of transportation. From policy planning to performance evaluation, from model development to impact studies, good quality data is essential to generate ideas and clear-cut solutions to be implemented by transportation professionals and decision makers.In order to improve scientific data quality and function within a continuous quality assessment and management framework, research and development organizations and agencies constantly look for the latest methodologies and technological tools of data management. The New York Metropolitan Transportation Council (NYMTC), for example, has awarded a research project titled “Improvements on NYMTC Data Products” to the authors of this paper in an effort to modernize the existing data products (i.e., reports and brochures, both printed and online) and improve the communication between the agency and the public. The main goal of the research project was to perform a through review and examination of NYMTC data products to identify specific issues about the existing data products, website and the current data maintenance process at NYMTC, and then suggest appropriate solutions, both data and website, and process oriented.This paper reports the results from this research project by giving special emphasis to the issues and solutions related to the data maintenance process.

Pre-Hospital Intubation Factors and Pneumonia in Trauma Patients

We reported similar rates of ventilator-associated pneumonia (VAP) previously in trauma patients intubated either in a pre-hospital (PH) venue or the emergency department. A subset of PH intubations with continuous quality assessment was re-examined to identify the intubation factors associated with VAP. The subgroup was derived from an existing data set of consecutive adult trauma patients intubated prior to Level I trauma center admission July 2007-July 2008. Intubation details recorded included bag-valve mask ventilation (BVM) and the presence of material in the airway. The diagnosis of VAP was made preferentially by quantitative bronchoalveolar lavage (BAL) cultures (≥ 10⁴ colony-forming units indicating infection). Baseline data, injury characteristics, and circumstances of intubation of patients with and without VAP were compared by univariable analysis. Detailed data were available for 197 patients; 32 (16.2%) developed VAP, on average 6.0±0.7 days after admission. Baseline characteristics were similar in the groups, but diabetes mellitus was more common in the VAP group (4 [12.5%] vs. 5 [3.0%]; p=0.02). There was a higher rate of blunt injury in the VAP patients (28 [87.5%] vs. 106 [64.2%]; p=0.01) and higher injury severity scores (33.1±2.8 vs. 23.0±1.0; p=0.0002) and chest Abbreviated Injury Scores (2.6±0.3 vs. 1.5±0.1; p=0.002). Lower Glasgow Coma Scale scores (7.9±0.9 vs. 9.9±0.4; p=0.04) and greater use of BVM (18 [56.3%] vs. 56 [34.0%]; p=0.02) were observed in patients who developed VAP. Among aspirations, 10 (31.3%) of patients with emesis developed VAP compared with only 4 (12.5%) with blood in the airway (p=0.003). Aspiration, along with depressed consciousness and greater injury severity, may predispose trauma patients to VAP. Prospective studies should focus on the quality and timing of aspiration relative to intubation to determine if novel interventions can prevent aspiration or decrease the risk of VAP after aspiration.

Establishing a quality assurance baseline for radiological protection of patients undergoing diagnostic radiology

Background. The wide use of ionising radiation in medical care has resulted in the largest man-made cause of radiation exposure. In recent years, diagnostic departments in Kenya have adapted the high-speed film/screen combination without well-established quality control, objective image quality criteria, and assessment of patient dose. The safety of patients in terms of justification and the as-low-as-reasonably-achievable (ALARA) principle is inadequate without quality assurance measures.
 Aim. This study assessed the level of film rejects, device performance, image quality and patient dose in 4 representative hospitals using high-speed film/screen combination.
 Results. The X-ray equipment quality control tests performance range was 67% to 90%, and 63% of the radiographs were of good diagnostic value. The measured prevalent chest examination entrance surface dose (ESD) showed levels above the international diagnostic reference levels (DRLs), while lumbar spine and pelvis examination was the largest source of radiation exposure to patients.
 Conclusion. The optimisation of patient protection can be achieved with optimally performing X-ray equipment, the application of good radiographic technique, and continuous assessment of radiographic image quality.

Iterative Evaluation in a Mobile Counseling and Testing Program to Reach People of Color at Risk for HIV—New Strategies Improve Program Acceptability, Effectiveness, and Evaluation Capabilities

This article highlights findings from an evaluation that explored the impact of mobile versus clinic-based testing, rapid versus central-lab based testing, incentives for testing, and the use of a computer counseling program to guide counseling and automate evaluation in a mobile program reaching people of color at risk for HIV. The program's results show that an increased focus on mobile outreach using rapid testing, incentives and health information technology tools may improve program acceptability, quality, productivity and timeliness of reports. This article describes program design decisions based on continuous quality assessment efforts. It also examines the impact of the Computer Assessment and Risk Reduction Education computer tool on HIV testing rates, staff perception of counseling quality, program productivity, and on the timeliness of evaluation reports. The article concludes with a discussion of implications for programmatic responses to the Centers for Disease Control and Prevention's HIV testing recommendations.

MAT-CHDSP, a novel medication assessment tool for evaluation of secondary prevention of coronary heart disease

Quality of health performance is of increasing international importance. The potential value of the implementation of a guideline-based medication assessment tool (MAT) has been evaluated in order to measure and improve adherence to guideline recommendations in secondary prevention of coronary heart disease (CHD). An existing MAT developed in the UK based on internationally recognised clinical evidence has been further developed [with criteria extended to secondary prevention of CHD only] for application in Norway. Content validity was demonstrated using a two round Delphi process among an expert group (12 reviewers, consensus threshold 75%). Inter- and intra-observer reliability testing was conducted with agreement expressed by Cohen's kappa (κ). The designed MAT was applied in a pilot study and application time was measured to inform clinical utility of the tool in real world settings. A total of 85 patients (69% male) undergoing coronary angiography were included. Mean age was 65.4 years (SD 11.6). The new MAT is named MAT-CHDSP and comprises 21 review criteria. Consensus among the expert group (n = 12) was obtained for all final criteria. Reliability testing showed κ in the range (0.79-0.90). Applicability in the pilot study was 63% (n = 1106) and adherence was 65%, 95% CI (64-66) (n = 791). The mean application time for the experienced user was 1.5 minutes (SD 0.3). MAT methodology might merge the increasing demand for continuous assessment of quality of health performance with the clinical pharmacist's need for a standardised and explicit working tool.

A New CMM-EDU Process Improvement and Assessment Model Using SEI-CMM Approach-Engineering Education Capability Maturity Model : (E2-CMM)

We propose a maturity model called E 2 -CMM, for computing and assessing Engineering education quality which is inspired by the Software Engineering Institute - Capability Maturity Model (SEI-CMM )[2]. Similar to CMM[22], the Capability Maturity Model for Engineering Education System (E 2 -CMM) can be used to rate educational sector according to their capability to deliver high quality education on a five level scale. Furthermore, E 2 -CMM can be used in order to improve an institution’s education capability by implementing the best practices and organizational changes it describes. In this paper, we explore a maturity model[1] suitable for educational sector to improve the standard and quality of an educational system. For this purpose, we have selected Capability Maturity Model (CMM) as our base model for developing E2-CMM framework for continuous quality assessment in education sector. . Finally, this paper concludes by describing the capability assessment methodology and an algorithmic approach for educational organization .

Systematic Classification of Morbidity and Mortality After Thoracic Surgery

Objective reporting of postoperative complications is the foundation of surgical quality assurance. We developed a system to identify both presence and severity of thoracic morbidity and mortality, and evaluated its feasibility and utility over the first two years of its implementation. The system was based on the Clavien-Dindo classification, in which the severity of a complication is proportional to the effort to treat it. Definitions were developed by peer review and questionnaire. All patients undergoing thoracic surgery (January 2008 to December 2009) were prospectively evaluated. A total of 953 patients (mean age 61 years; range, 14 to 95) underwent thoracic surgery (total # cases 1260), of which 369 patients had at least one complication (29.3% procedures). Grades I and II include minor complications requiring no therapy or pharmacologic intervention only. Grades III and IV are major complications that require surgical intervention or life support. Grade V complications result in patient death. Grades I, II, III, and IV complications comprised 4.9%, 63.9%, 21.1%, and 7.8% of all complications; overall mortality rate (grade V) was 2.2%. The most common complications were prolonged air leak (18.8%) and atrial fibrillation (18.2%) after pulmonary resection, and atrial fibrillation (11.5%) after esophagectomy-gastrectomy. Prolonged air leak led to a major complication (13%), readmission (17%), or prolonged hospital stay (29%) to a greater extent than atrial fibrillation (3%, 2%, and 7%, respectively). This standardized classification system for identifying presence and severity of thoracic surgical complications is feasible, facilitates objective comparison, identifies burden of illness of individual complications, and provides an effective method for continuous surgical quality assessment.

Primary percutaneous intervention of ST-elevation myocardial infarction in Austria: Results from the Austrian acute PCI registry 2005–2007

Primary percutaneous coronary intervention (PPCI) has become the preferred reperfusion strategy in ST-elevation myocardial infarction (STEMI). Implementation of networks of care and registries providing continuous quality assessment are key components for optimal management in patients with STEMI. To analyze procedural success and in-hospital outcome of interventional therapy of STEMI in Austria. We evaluated a total number of 4016 consecutive STEMI patients registered in the first three years after implementation of the Austrian acute PCI registry in January 2005. The rate of PPCI as an indication for acute coronary intervention increased from 83.5% in 2005 to 92.4% in 2007 (P < 0.0001). During this period the median door-to-balloon time decreased from 60.0 (40.0-90.0) min to 53.0 (30.0-80.0) min (P = 0.012). The percentage of patients receiving adequate adjunctive antithrombotic therapy with ASA/heparin and clopidogrel significantly increased (78.8-85.1% and 67.8-90.3%, respectively; P < 0.001). Overall in-hospital mortality was 9.6% in rescue PCI, 6.4% in facilitated PCI and 5.1% in PPCI. On multivariate analysis, cardiogenic shock (OR: 20.21, 95% CI: 12.21-33.44, P < 0.001), resuscitation (OR: 2.62, 95% CI: 1.47-4.69, P = 0.01), age (OR: 1.04, 95% CI: 1.02-1.06, P < 0.001) and angiographic success (OR: 5.93, 95% CI: 3.33-10.57, P < 0.001) were independent predictors of in-hospital death. Continuous nationwide efforts to establish regional networks for STEMI treatment in the years 2005-2007 led to a decrease in door-to-balloon time, improved adjunctive antithrombotic therapy and an in-hospital mortality of 5%. Results of interventional STEMI treatment in Austria are in accordance with current guidelines and with other contemporary registries.

Continuous quality assessment of atmospheric water vapour measurement techniques: FTIR, Cimel, MFRSR, GPS, and Vaisala RS92

Abstract. At the Izaña Observatory, water vapour amounts have been measured routinely by different techniques for many years. We intercompare the total precipitable water vapour (PWV) amounts measured between 2005 and 2009 by a Fourier Transform Infrared (FTIR) spectrometer, a Multifilter Rotating Shadow-band Radiometer (MFRSR), a Cimel sunphotometer, a Global Positioning System (GPS) receiver, and daily radiosondes (Vaisala RS92). The long-term characteristics of our study allows a reliable and extensive empirical quality assessment of long-term validity, which is an important prerequisite when applying the data to climate research. We estimate a PWV precision of 1% for the FTIR, about 10% for the MFRSR, Cimel, and GPS (when excluding rather dry conditions), and significantly better than 15% for the RS92 (the detection of different airmasses avoids a better constrained estimation). We show that the MFRSR, Cimel and GPS data quality depends on the atmospheric conditions (humid or dry) and that the restriction to clear-sky observations introduces a significant dry bias in the FTIR and Cimel data. In addition, we intercompare the water vapour profiles measured by the FTIR and the Vaisala RS92, which allows the conclusion that both experiments are able to detect lower to upper tropospheric water vapour mixing ratios with a precision of better than 15%.

A New Framework for Measuring the Quality of Engineering Education System using SEI-CMM approach - (E2-CMM)

We propose a maturity model for computing education which is inspired by the Capability Maturity Model (CMM) used in software engineering. Similar to CMM, the Capability Maturity Model for Engineering Education System (E 2 -CMM) can be used to rate educational sector according to their capability to deliver high quality education on a five level scale. Furthermore, E 2 -CMM can be used in order to improve an institution’s capability by implementing the best practices and organizational changes it describes. In this paper we explore a maturity model suitable for educational sector to improve the standard and quality of an educational system. For this purpose we have selected SEI-CMM as our base model for developing E2-CMM framework, which can be used for continuous process and quality assessment in education sector. Finally, this paper concludes with a brief discussion on the capability assessment and rating methodology that can be used for ranking the level of maturity of the educational organization.

Erreurs d'identification des patients dans un local d'archives vivantes

The aim of this study was to quantify and qualify mistaken identities in a current medical records archive. The medical records are classified by identification indexes (day and month of birth, the first letter of their surname) by category where their placement is a function of the record's status defined as "current", "semi-current" or "dead". All of the medical records marked as "current" (n=43,592), dating between 12 February 2004 to 11 March 2004, were analysed. 1397 (3.2%) contained at least one error, totalling 1456 errors, or an average of 1.04 errors per record. The errors were classified into two types: misidentification (1254 or 86.1%) and logistical errors (202 or 13.9%). 256 serious mistakes were identified as representing 17.6% of the cases. The staff costs associated with managing these errors totalled 12,408 Euro, corresponding to a cost of 8.88 Euro per error. The immediate impact is a reduction in the workload of staff directly due to the absence of the missing file. The depth of this problem was more significant than had been suggested by the indicators, both qualitatively and quantitatively. These results should be used to advocate for the implementation of a policy on continuous quality assessment (scoring the quality of the creation of the record, and scoring the intervention).

Tool Support for Continuous Quality Control

Over time, software systems suffer gradual quality decay and therefore costs can rise if organizations fail to take proactive countermeasures. Quality control is the first step to avoiding this cost trap. Continuous quality assessments help users identify quality problems early, when their removal is still inexpensive; they also aid decision making by providing an integrated view of a software system's current status. As a side effect, continuous and timely feedback helps developers and maintenance personnel improve their skills and thereby decreases the likelihood of future quality defects. To make regular quality control feasible, it must be highly automated, and assessment results must be presented in an aggregated manner to avoid overwhelming users with data. This article offers an overview of tools that aim to address these issues. The authors also discuss their own flexible, open-source toolkit, which supports the creation of dashboards for quality control.

Doing Things Differently

Doing Things Differently

An External Quality Assessment Of Haematology Laboratories-A Ghanaian Experience

Developed countries have guaranteed the quality of clinical laboratories through quality assurance programmes. However, these programmes have not received the needed attention in Ghanaian haematology laboratories, as is the case in many developing countries where visual counting of blood cells are the usual procedures. To assess the level of analytical quality of haematology laboratories in the Ashanti region of Ghana, form of an external quality assessment scheme was undertaken. The survey covered twelve haematology laboratories in both the public and the private sectors. Control blood samples were sent to the laboratories to be analyzed. The study, which lasted for five months, covered such routine haematological parameters as Hb, PCV, Total WBC and platelets. The results from these laboratories were compared to that of an automated cell counter using the Cell-Dyn 3700 (Abbot Diagnostic Division, USA). About 80% of the laboratories studied which were using the manual counting, achieved the medically accepted analytical performance for all the parameters except platelets, where the percentage of the laboratories dropped to about 70%. The study has established the need for a continuous internal and external quality assessment in haematology. Such practice together with continuous education of laboratory personnel and the provision of automated instruments will help to achieve optimum laboratory quality needed for proper health care delivery in the country. Keywords: External quality assessment, haematology laboratories, Ghana. Journal of Science and Technology Vol. 28 (1) 2008 pp. 17-22

Guidelines for Therapy of ST-Segment–Elevation Acute Myocardial Infarction in Patients Presenting to Partners HealthCare System Hospital Emergency Departments

A major focus for individuals and organizations that study the quality of cardiovascular care is the timeliness of treatment for those patients who suffer an acute ST-elevation myocardial infarction (STEMI). We sought to develop guidelines that would inform the development and management of a more standardized approach to the treatment of STEMI within the 5 acute care hospitals that make up the Partners Healthcare acute care hospital network. In recent years much has been learned about how to deliver timely reperfusion therapy in STEMI and how to assess its outcome. As a component of the organization's mandate to promote the uniform high quality of care throughout the system, our group began studying the many aspects of the current treatment of STEMI within the system, we reviewed, summarized and debated the relevant literature, studied best practices and made recommendations for a system-wide approach to this problem. Our methods have included literature review, consultation with local and national experts, site visits throughout the system, web-based surveys of current attitudes within the system, interviews with stakeholders and consensus-development conferences. The result was not only the development of the following guidelines for therapy, but also an ongoing commitment to share patient-level data and outcomes for continuous quality assessment and improvement.