Continuous Quality Improvement Methodology Research Articles

Controlling Hypertension through Education and Coaching in Kidney Disease (CHECK-D): protocol of a cluster randomised controlled trial

IntroductionChronic kidney disease (CKD) affects 30 million Americans. Early management focused on blood pressure (BP) control decreases cardiovascular morbidity and mortality. Less than 40% of patients with CKD achieve recommended...

A Data Quality Framework for the European Health Data Space for secondary use

Abstract A cornerstone in the development of the European Health Data Space for secondary use of data (EHDS2) is the design, implementation and assessment of a Data Quality Framework (DQF). Consistently, the Joint Action TEHDAS has a dedicated work program where, learning from others’ experiences across Europe and abroad, the work package is building the concepts and methods for such a DQF. The scope of this work program is to provide recommendation to the Member States and the European Commission on the concept of DQF to foster, where (institutions) the DQF should be implemented, when in data life cycle, how should be implemented and by whom. In terms of the concept, the DQF raises the importance of quality assurance procedures at data processor level and the level of quality of the data collections in terms of reliability, relevance, timeliness, coherence, coverage and completeness. When it comes to when along the data life cycle, DQF is expected operate when data needs harmonization at data processor level (ie, the effective application of interoperability standards), in the publication of the data sources (ie providing users knowledge on the provenance of data and the content of data source); or, when data sources have to be integrated and sensitive data pseudonymized (ie, the quality of the linkage and losses after pseudonymisation). Finally, when it comes to the methodology, TEHDAS suggests a three-fold approach - some quality measures in the DQF could be translated into legislation (eg, the requirement of regular auditing for a data processor to be a trusted party in the EDHS2); some could be kept as good-practices (eg, recommendation of archival procedures when a research project finalizes); and, under the assumption of continuous data quality improvement, an assessment, benchmarking and promotion methodology (eg, a grading system at data processor level).

G Is for Geometric: A G-Chart Primer for Surgeons

In this issue of The Annals of Thoracic Surgery, Glenn and colleagues1 detail their experience with development, implementation, monitoring, and evaluation of a surgical wound infection (SWI) prevention bundle in a high-volume congenital heart surgery program. The study is a valuable and elegant example of applied modern continuous quality improvement (CQI) methodology, and I applaud the authors for their contribution. The authors’ use and evaluation of g-charts should be highlighted. A g-chart is a type of statistical process control (SPC) chart.

Implementing Lean Six Sigma Concepts in Audiology Practices

Implementing Lean Six Sigma Concepts in Audiology Practices

S128: CONTINUOUS QUALITY IMPROVEMENT IN PAEDIATRIC SICKLE CELL DISEASE

Background: Sickle cell disease (SCD) is characterised by severe episodic pain requiring prompt and effective analgesia. However, SCD patients frequently experience poor quality of care due to lack of awareness of the condition among non- specialist staff, pre-conceived biases and unfounded allegation of drug-seeking behaviour. Several reports and surveys using Patient Reported Experience Measure (PREM) tools indicate widespread prevalence of ineffective pain relief in emergency department(ED), poor access to psychological therapies and poor funding for service development. Aims: To use a validated PREM tool to survey patients or carers of sickle cell disease within the paediatric service of a Specialist Haemoglobinopathy Team. To use an established Continuous Quality Improvement (CQI) methodology (5-D’s-define, describe, design, deliver, digest) to ensure sustained improvement in patient- reported areas of service deficit. Methods: The PREM survey was conducted as part of a network- wide initiative in 2018. The survey responses were analysed and problem scores created for specialist care, emergency care, ward-based care, information and support. These problem areas were categorised into domains where further improvement action was needed. CQI tools were used to map the patient journey within Emergency Department (ED) when presenting with pain followed by thematic analysis to identify potential improvements in the patient journey. Results: The PREM survey analysis identified three domains for improvement: Domain A: To improve the effectiveness of pain relief and quality of empathic and informed care to paediatric sickle cell patients and their families in ED. We developed multi-disciplinary teaching videos with patient involvement and patient information material based on ED/pain/sickle staff feedback. Excellent engagement from all staff groups obtained. Patient involvement in ED teaching video was well received. Thematic analysis of ED process mapping highlighted need for sustained staff education and re-writing ED pain protocol to align with current practice. Pre-conceived biases were identified among staff with respect to attributing drug-seeking behaviour to patients during severe sickle cell pain. Domain B: To improve the information presented to children regarding SCD and the care services available in our trust We developed child friendly Information leaflets targeting primary school age and secondary school age readers Domain C: To improve the availability of, and access to, mental health services for paediatric SCD patients. We developed virtual parent support groups and psychological health screening for adolescent patients in clinics. We organised a ‘Tree of Life’ (ToL) patient empowerment workshop. The parent support groups were well attended. Plans are in place to continue ToL workshops and support groups on a regular basis. Future work: A rapid improvement workshop is being planned to engage a wider multi-disciplinary team to engender a culture of empathy in line with our trust values. Further input from workshop is expected to identify and implement sustainable goals. We plan to undertake a repeat PREM survey following the end of this CQI project to understand the impact and the implemented improvements.

An evaluation of Lean and Six Sigma methodologies in the national health service

PurposeThe purpose of this paper is to conduct an empirical study derived from the previous literature from the perspective of benefits, tools and techniques, continuous improvement (CI) and quality improvement (QI) methodologies and critical failure factors (CFFs) of Lean and Six Sigma (SS) in the national health service (NHS).Design/methodology/approachA literature review was carried out to identify previous findings, empirical data and critical variables concerning Lean and SS in healthcare for over ten years. Second, primary research in quantitative surveys and qualitative interviews was carried out with 110 participants who have experience using Lean and SS in the NHS.FindingsLean and SS have evolved into common practices within the NHS and now have an established list of tools and techniques frequently employed by staff. Lean and SS are considered robust CI methodologies capable of effectively delivering extensive benefits across many different categories. The NHS must overcome a sizable amount of highly important CFFs and divided organizational culture.Originality/valueThis paper has developed the most extensive empirical study ever produced on Lean and SS in the NHS and has expanded on previous works to create new and updated research. The findings produced in this paper will assist NHS medical directors and practitioners in obtaining up-to-date insight into Lean and SS status in the NHS. The paper will also guide the NHS to critically evaluate their current CI strategy to ensure long-term sustainability and deliver improved levels of service to patients.

Applying the Plan-Do-Study-Act cycle in medical education to refine an antibiotics therapy active learning session

BackgroundActive learning improves learner engagement and knowledge retention. The application of continuous quality improvement methodologies, such as the Plan-Do-Study-Act (PDSA) framework, may be useful for optimizing medical education, including active learning sessions. We aimed to enhance student satisfaction and achievement of learning outcomes by applying the PDSA framework to an antibiotic utilization curriculum for medical students.MethodsGuided by the Plan-Do-Study-Act framework, between February 2017 and July 2019, we developed, implemented, and revised an active learning session for medical students, focused on appropriate utilization of antibiotics during their Internal Medicine clerkship.ResultsAcross twelve sessions, 367 students (83.4%) completed the post-evaluation survey. Although baseline ratings were high (97% of respondents enjoyed the “active learning” format), constructive comments informed iterative improvements to the session, such as modifying session timing, handouts and organization of the gaming component. Intervention 3, the last improvement cycle, resulted in more favorable ratings for the active learning format (p = 0.015) improvement in understanding antibiotics and their clinical application (p = 0.001) compared to Baseline ratings.ConclusionsThis intervention suggests that active learning, with regular incorporation of student feedback vis-à-vis a PDSA cycle, was effective in achieving high student engagement in an Internal Medicine core clerkship session on antibiotic therapy. Iterative interventions based on student feedback, such as providing an antibiotic reference table and answer choices for each case, further improved student receptivity and perceived educational value. The study findings have potential implications for medical education and suggest that the application of the PDSA cycle can optimize active learning pedagogies and outcomes.

Quality improvement report: setting up a staff well-being hub through continuous engagement

The coronavirus pandemic has presented a new set of challenges for the frontline National Health Service staff. It is not only the long working hours but also the uncertainty and...

Measuring the continuous quality improvement orientation of medical education programs.

There is a growing interest in applying continuous quality improvement (CQI) methodologies and tools to medical education contexts. One such tool, the "Are We Making Progress" questionnaire from the Malcolm Baldrige National Quality Award framework, adequately captures the dimensions critical for performance excellence and allows organizations to assess their performance and identify areas for improvement. Its results have been widely validated in business, education, and health care and might be applicable in medical education contexts. The measurement properties of the questionnaire data were analyzed using Rasch modeling to determine if validity evidence, based on Messick's framework, supports the interpretation of results in medical education contexts. Rasch modeling was performed since the questionnaire uses Likert-type scales whose estimates might not be amenable to parametric statistical analyses. Leaders and teachers at 16 of the 17 Canadian medical schools were invited in 2015-2016 to complete the 40-item questionnaire. Data were analyzed using the ConQuest Rasch calibration program, rating scale model. 491 faculty members from 11 (69 percent) schools participated. A seven-dimensional, four-point response scale model better fit the data. Overall data fit to model requirements supported the use of person measures with parametric statistics. The structural, content, generalizability, and substantive validity evidence supported the interpretation of results in medical education contexts. For the first time, the Baldrige questionnaire results were validated in medical education contexts. Medical education leaders are encouraged to serially use this questionnaire to measure progress on their school's CQI focus.

Blood Culture Contamination: Educational Roadmap to Improvement

BACKGROUND Blood culture contamination (BCC) leads to diagnostic uncertainty in clinical management. It contributes to increased health care costs, prolong hospitalization, delay or incorrect changes to patient management and increase laboratory workload. Research indicates average cost for contaminated blood culture $6,000. September 2014 the Emergency Department (ED) BCC rate was 6.4% compared to the current national benchmark rates 2-3% (Avg. 2.5%). METHODS Collaboration with ED nurse educators, Micro Consolidation Laboratory leader, and Infection Preventionist utilizing Continuous Quality Improvement (CQI) methodology resulted in the development of an educational program utilizing evidence based practice, a focus on standardization of process bundling of supplies, improved Blood culture specimen equipment, and updating BCC reporting systemto better monitor infection rates at staff level. A consistent process was established, blood culture collection kits created, all staff attended mandatory training, feedback provided to staff monthly along with coaching, mentoring, and re-education of staff with contaminants implemented. RESULTS Pre implementation ED BCC rates 6.4% support the hypothesis that basic asepsis principles were not understood or followed, there was a lack of knowledge related to good blood culture blood sampling practice, inconsistent processes by all staff members, and lack of understanding the importance for appropriate timing for drawing sample related to start of antibiotics. Blood culture contamination rates decreased following mandatory education and monthly monitoring of individual contamination rates, ongoing coaching, mentoring and re-education when appropriate. Post implementation ED was able to decrease BCC rates to yearly department rate of 2.5% for 2015. The ED has sustained this improvement through 2018 with consistent monthly rates less than 2% and as low as 0.7%. CONCLUSIONS An evidence based bundle approach, consistent implementation, ability to provide staff level BCC rates along with appropriate feedback, mentoring, coaching will support a sustainable improvement in BCC rates in the ED.

Continuous quality improvement methodology: a case study on multidisciplinary collaboration to improve chlamydia screening.

This article illustrates quality improvement (QI) methodology using an example intended to improve chlamydia screening in women. QI projects in healthcare provide great opportunities to improve patient quality and safety in a real-world healthcare setting, yet many academic centres lack training programmes on how to conduct QI projects. The choice of chlamydia screening was based on the significant health burden chlamydia poses despite simple ways to screen and treat. At the University of Michigan, we implemented a multidepartment process to improve the chlamydia screening rates using the plan-do-check-act model. Steps to guide QI projects include the following: (1) assemble a motivated team of stakeholders and leaders; (2) identify the problem that is considered a high priority; (3) prepare for the project including support and resources; (4) set a goal and ways to evaluate outcomes; (5) identify the root cause(s) of the problem and prioritise based on impact and effort to address; (6) develop a countermeasure that addresses the selected root cause effectively; (7) pilot a small-scale project to assess for possible modifications; (8) large-scale roll-out including education on how to implement the project; and (9) assess and modify the process with a feedback mechanism. Using this nine-step process, chlamydia screening rates increased from 29% to 60%. QI projects differ from most clinical research projects by allowing clinicians to directly improve patients’ health while contributing to the medical science body. This may interest clinicians wishing to conduct relevant research that can be disseminated through academic channels.

Establishing a familial hypercholesterolaemia register - The first year

Background and aimsFamilial hypercholesterolemia (FH) is an autosomal dominant condition raising the risk of premature cardiovascular disease up to twentyfold.[1] [2] It is under-diagnosed and undertreated, in spite of availability of effective treatment. Registers are recommended to assist in the recognition and improvement of the condition since treatment reduces morbidity and mortality. Disease registers enable longitudinal review and the application of continuous quality improvement methodology. The aims of this paper are to describe the process of setting up a new FH register in Malta based on phenotype, the preliminary results achieved, the barriers encountered, how these were overcome, and future plans for development. MethodsThe registry was established as an observational clinical study designed for a small healthcare system with limited resources. Effective process design requires attention to standards, capacity, outcome measurement and feedback, which have been incorporated. Results43 individuals have been registered applying Dutch Lipid Clinic Network standards, including 9 Definite, 16 Probable and 18 Possible FH. Cascade testing has identified three younger, and one older FH individuals; amenable risk factors and target outcomes are available for feedback and action. Barriers included insufficient infrastructure, limited stakeholder involvement, time limitations impacting clinical care and data collection, poor recognition, awareness and referral, and limited cascade testing. Overcoming these required persistence, reorganizing clinical work, with some assistance from clinic nurses, forward planning to involve patients and raising FH awareness through presentations to various audiences. ConclusionsDuring this year the register was established and is functional: awareness is being raised. Future steps will target process improvement for effectiveness and sustainability.

Abstract TP398: Improving Tpa Utilization and Door to Tpa Times in a Community Hospital: Lessons Learned

Objective: To improve door to thrombolysis time to less than 60 minutes for acute stroke patients in a community hospital with telestroke access. Background: Earlier initiation of thrombolysis (tPA) therapy in acute stroke patients is associated with improved patient outcomes. Delays in the identification and workup of stroke patients can impact thrombolysis treatment time. Methods: A multidisciplinary workgroup was created in 2015. The care of stroke alert patients was observed over several weeks, identifying barriers and delays in treatment. Multiple interventions were implemented utilizing plan-do-study-act (PDSA) cycles. Door-to-tPA (DTT) times were retrospectively collected for patients with final diagnosis of ischemic stroke and monitored monthly using statistical process control charts. Results: Baseline average DTT was 77 minutes. Initiation of a stroke launch pad and revision of the process to obtain CT scans resulted in a significant decrease in average time to CT to 9 minutes, which was sustained, but without subsequent improvement in DTT times. Further interventions to the stroke alert process improved DTT times transiently but performance was not sustainable. Multiple PDSA cycles were carried out targeting various inefficiencies in the process, knowledge gaps amongst staff, and cultural barriers within the ER physicians. DTT times have gradually improved over time, with average DTT of 48 minutes achieved for Jan-June 2018 (Figure 1). The average number of tPA cases per month increased from 1.3 in 2015 to 2.5 in 2017-2018, likely attributable to revisions in the stroke alert process and stroke alert criteria, and staff education. Conclusion: Continuous quality improvement methodology can be utilized to improve door to tPA times in acute stroke patients. This may require multiple PDSA cycles, addressing cultural and educational barriers, as well as continually revisiting the process to ensure sustained performance.

The MONARCH intervention to enhance the quality of antenatal and postnatal primary health services in rural South Africa: protocol for a stepped-wedge cluster-randomised controlled trial

BackgroundGaps in maternal and child health services can slow progress towards achieving the Sustainable Development Goals. The Management and Optimization of Nutrition, Antenatal, Reproductive, Child Health & HIV Care (MONARCH) study will evaluate a Continuous Quality Improvement (CQI) intervention targeted at improving antenatal and postnatal health service outcomes in rural South Africa where HIV prevalence among pregnant women is extremely high. Specifically, it will establish the effectiveness of CQI on viral load (VL) testing in pregnant women who are HIV-positive and repeat HIV testing in pregnant women who are HIV-negative.MethodsThis is a stepped-wedge cluster-randomised controlled trial (RCT) of 7 nurse-led primary healthcare clinics to establish the effect of CQI on selected routine antenatal and postnatal services. Each clinic was a cluster, with the exception of the two smallest clinics, which jointly formed one cluster. The intervention was applied at the cluster level, where staff received training on CQI methodology and additional mentoring as required. In the control exposure state, the clusters received the South African Department of Health standard of care. After a baseline data collection period of 2 months, the first cluster crossed over from control to intervention exposure state; subsequently, one additional cluster crossed over every 2 months. The six clusters were divided into 3 groups by patient volume (low, medium and high). We randomised the six clusters to the sequences of crossing over, such that both the first three and the last three sequences included one cluster with low, one with medium, and one with high patient volume.The primary outcome measures were (i) viral load testing among pregnant women who were HIV-positive, and (ii) repeat HIV testing among pregnant women who were HIV-negative. Consenting women ≥18 years attending antenatal and postnatal care during the data collection period completed outcome measures at delivery, and postpartum at three to 6 days, and 6 weeks. Data collection started on 15 July 2015. The total study duration, including pre- and post-exposure phases, was 19 months. Data will be analyzed by intention-to-treat based on first booked clinic of study participants.DiscussionThe results of the MONARCH trial will establish the effectiveness of CQI in improving antenatal and postnatal clinic processes in primary care in sub-Saharan Africa. More generally, the results will contribute to our knowledge on quality improvement interventions in resource-poor settings.Trial registrationThis trial was registered on 10 December 2015: www.clinicaltrials.gov, identifier NCT02626351.

Closing the gaps to eliminate mother-to-child transmission of HIV (MTCT) in South Africa: Understanding MTCT case rates, factors that hinder the monitoring and attainment of targets, and potential game changers

Background. Ninety percent of the world’s HIV-positive pregnant women live in 22 countries. These 22 countries, including South Africa (SA) have prioritised the elimination of mother-to-child transmission of HIV (EMTCT). Since 2016 all 22 countries recommend lifelong antiretroviral treatment for all HIV-positive pregnant and lactating women. To measure South African national, provincial and district-level progress towards attaining EMTCT, we analysed the number of in utero (IU) paedatric HIV infections per 100 000 live births (IU case rate), and synthesised factors hindering the monitoring of EMTCT progress and attainment from the viewpoint of provincial and district-level healthcare managers and implementers. We highlight potential innovations to strengthen health systems and improve EMTCT programme delivery. Methods. We reviewed national-, provincial- and district-level birth HIV testing data from routine National Health Laboratory Services (NHLS) records between April 2016 and March 2017. To obtain a qualitative perspective from healthcare managers and implementers, we synthesised information from the nine 2016 provincial-level EMTCT stock-taking workshops. These workshops involve key provincial and district-level staff, mentors and supporting partners. Lastly, we highlight potential innovations presented at these workshops to overcome operational challenges. Results. The national IU mother-to-child transmission (MTCT) rate was 0.9%, which translated to an IU case rate of 245 HIV-positive neonates per 100 000 live births. Provincial IU percent MTCT risk ranged from 0.6% to 1.3%, with IU case rates ranging between 168 and 325 cases per 100 000 live births. District-level IU percent MTCT risk ranged from 0.4% to 1.9%. Potential game changers include: pre-conception counselling to optimise maternal-partner health, weekly dissemination of HIV polymerase chain reaction (PCR) and viral load reports from the NHLS to specific individuals who trace mothers and infants needing care, use of ward-based outreach teams and community caregivers to trace HIV-infected mothers and their infants to link them into care, inclusion of a unique identifier in patient-held infant Road to Health booklets to facilitate infant tracing and continuous quality improvement (CQI) processes within facilities and districts and implementation of an HIV-positive baby tool to understand the characteristics and risks of HIV-positive infants. On an ecological level, provinces and districts using community-based approaches and CQI methodology seemed to have lower MTCT and IU case rates. Conclusions. More quantitative analyses are needed to understand what proportion of the success can be attributed to community-based and CQI approaches and the impact of the potential game changers on progress towards EMTCT.

CICLO PDCA PARA ELABORAÇÃO DE CHECKLIST DE SEGURANÇA CIRÚRGICA

O estudo objetivou utilizar metodologia de melhoria contínua da qualidade na elaboração de checklist de segurança cirúrgica para os períodos pré e pós-operatório em unidades de internação. Realizou-se pesquisa participante com 16 enfermeiras, em oito unidades cirúrgicas de um hospital universitário do sul do Brasil, entre março de 2013 e outubro de 2014. A elaboração conjunta do checklist foi norteada pelo ciclo de melhoria contínua e Programa Cirurgias Seguras Salvam Vidas. O checklist foi submetido a teste piloto com 450 instrumentos preenchidos e analisados por estatística descritiva. Após ajustes decorrentes da avaliação, foi aprovado com o título “Checklist de Segurança Cirúrgica Pré e Pós-operatório”, com 85 indicadores agrupados em seis categorias: I) Identificação, II) Pré-operatório, III) Pós-operatório Imediato, IV) Pós-Operatório Mediato, V) Complicações e VI) Alta Hospitalar/transferência. O instrumento pode contribuir para ações preventivas de erros, monitorar sinais e sintomas e produzir indicadores para assistência segura ao paciente cirúrgico.

Sharing Coordination of Health Services on Flinders Island using an applied continuous quality improvement approach

Flinders Island is located in the north of Tasmania, with population of approximately 700 residents. Flinders Islanders are significantly older than Tasmanian and Australian averages, with high rates of avoidable mortality and living in one of Tasmania’s most socioeconomically disadvantaged regions. They have a large Aboriginal and Torres Strait Islander population, sparsely situated communities, a lack of public transport paired, costly fuel, fragmented service funding streams and intermittent fly-in outreach services. Stakeholders identified that coordinating available care was a critical factor to ensure a high risk population received care that was both appropriate to its needs and efficient in terms of local resourcing. The Flinders Island Aboriginal Association Inc. (FIAAI), government funded Multipurpose Centre (MPC) and Primary Health Tasmania (PHT) convened 10 multidisciplinary working group meetings to review 11 case studies of Flinders Islanders living with complex health needs between November 2015 and May 2016. The local general practice participated in working groups and an independent clinical facilitator interviewed consenting local residents for case study material. An applied continuous quality improvement (CQI) approach was used to identify barriers, enablers and opportunities. The aim was to improve the coordination of care for the people on Flinders Island living with complex health needs. The theory of change was that bringing stakeholders together to review common cases would enable them to identify common opportunities and the feasibility of testing these to improve the coordination of care for Flinders Islanders. Patient stories, combined with the facilitator’s clinical expertise, focussed case review sessions on problem solving for actual patients whom the providers around the table could identify with. Working group participants reporting increased motivation to involve patients and be stronger advocates for systems level processes that might contribute to improving their care. Noticeable cultural change was achieved within the provider group that participated in this project; improved inter-personal and inter-organisational provider relationships are a key requirement to ensure the sustainability of activity towards improved coordination of care for Flinders Islanders. The degree to which this cultural change is sustained is dependent upon multiple ongoing factors including staff availability and stability within the three organisations, the maintenance of cooperative interpersonal and inter-organisational relationships and sustained momentum. The CQI methodology is applicable and transferable to other scenarios where multiple providers service patient groups due to the use of patient centred case reviews which aid in focussing provider perspectives on common challenges and opportunities. This project brought together stakeholders to review current local practices and identify opportunities to overcome existing barriers to coordination of patient care on Flinders Island. It enhanced communication, coordination and planning between previously disparate providers. It enabled local identification of activities to sustain gains using a time delimited, locally sustainable and transferrable methodology. It has highlighted the importance of inter-provider relationships, the justification for change, change readiness and patient centred care in efforts to improve the coordination of health care delivery.

Acute Spinal Cord Compression: CQI Framework Increases Resource Efficiency While Promoting Delivery of High-Quality Care

PurposeLiterature reports indicate that advanced imaging is overutilized, especially in the emergency setting. At our institution, stat spinal MRI for suspected acute spinal cord compression (ASCC) was perceived to be excessively utilized. A continuous quality improvement process was employed to investigate this trend and improve the efficiency of this diagnosis. MethodsSpine imaging in patients with suspected ASCC was retrospectively evaluated for appropriateness of indications and quality of imaging. Based on the results, a new institutional policy for ordering MR for suspected ASCC was implemented, concurrent with development of a new screening spine MRI protocol. Subsequently, indications, efficacy, and imaging utilization of the new strategy were analyzed for improved operational effectiveness. ResultsThe initial retrospective study demonstrated only a 1.4% positive rate of ASCC as well as image-quality degradation due to patient motion resulting from prolonged scan times. Based on these results, a new institutional policy for ordering stat ASCC spine MRI was instituted with an updated screening MRI protocol. This policy resulted in a positive rate of ASCC of 4.4%, and decreased scan time by 50%-70%, while preserving diagnostic image quality and decreasing resource utilization. ConclusionsAs suspected, stat spinal MRI for ASCC was excessively utilized at our institution. The study demonstrated that systemic improvements regarding this issue can be achieved by using a multidisciplinary approach and following a continuous quality improvement methodology. A new MRI protocol for identification of ASCC was found to preserve image quality and diagnostic confidence, while simultaneously decreasing scan time and use of valuable health care resources.

Review of continuous quality improvement methodology - enablers, exertion, benefits for SMEs

The SMEs are often the suppliers of the larger companies, particularly in automobile sector; hence the changes in the large companies affect the SMEs. On one side automobile industry is growing and on other side sales are decreasing. OEMs are now making mandatory to implement QI tools and techniques especially automotive core tools through ISO/TS 16949 certification for their suppliers. The aim of this paper is to review the enablers, exertions, benefits and existing research on CQI with special emphasis on automobile sector SMEs. The methodology uses e xtensive review of literature through reputed publications – journals, conference proceedings, research thesis, etc. This paper provides an overview of CQI drives, its enablers, and exertions, how it evolved into sophisticated methodologies and benefits used in organisations especially in SMEs. It should be of value to practitioners of CQI programmes and to academics who are interested in how CQI has evolved, and where it is today.

“The 3/3 Strategy”: A Successful Multifaceted Hospital Wide Hand Hygiene Intervention Based on WHO and Continuous Quality Improvement Methodology

BackgroundOnly multifaceted hospital wide interventions have been successful in achieving sustained improvements in hand hygiene (HH) compliance.Methodology/Principal FindingsPre-post intervention study of HH performance at baseline (October 2007– December 2009) and during intervention, which included two phases. Phase 1 (2010) included multimodal WHO approach. Phase 2 (2011) added Continuous Quality Improvement (CQI) tools and was based on: a) Increase of alcohol hand rub (AHR) solution placement (from 0.57 dispensers/bed to 1.56); b) Increase in frequency of audits (three days every three weeks: “3/3 strategy”); c) Implementation of a standardized register form of HH corrective actions; d) Statistical Process Control (SPC) as time series analysis methodology through appropriate control charts. During the intervention period we performed 819 scheduled direct observation audits which provided data from 11,714 HH opportunities. The most remarkable findings were: a) significant improvements in HH compliance with respect to baseline (25% mean increase); b) sustained high level (82%) of HH compliance during intervention; c) significant increase in AHRs consumption over time; c) significant decrease in the rate of healthcare-acquired MRSA; d) small but significant improvements in HH compliance when comparing phase 2 to phase 1 [79.5% (95% CI: 78.2–80.7) vs 84.6% (95% CI:83.8–85.4), p<0.05]; e) successful use of control charts to identify significant negative and positive deviations (special causes) related to the HH compliance process over time (“positive”: 90.1% as highest HH compliance coinciding with the “World hygiene day”; and “negative”:73.7% as lowest HH compliance coinciding with a statutory lay-off proceeding).Conclusions/SignificanceCQI tools may be a key addition to WHO strategy to maintain a good HH performance over time. In addition, SPC has shown to be a powerful methodology to detect special causes in HH performance (positive and negative) and to help establishing adequate feedback to healthcare workers.