Continuous Quality Improvement Team Research Articles

573 Proforma for Referrals to the Paediatric Surgery Ward from General Practice (GP) Surgeries and Urgent Care Centres for Foundation Year One (FY1) Doctors

Abstract Introduction The foundation year one (FY 1) doctors hold a bleep and receive referrals from primary care centres especially from the General Practice (GP) surgeries and Urgent Care centres. For many FY 1 doctors, this job may be their first experience in the NHS in taking referrals and it could be quite challenging to take a good referral from primary care centres in the NHS. This was the basis to conduct this quality improvement project (QIP) to help the FY 1 doctors in taking good primary care referral documentation. Aim To develop a primary care centre referral proforma as a guide for the FY 1 doctors in taking referrals and to assess the junior doctors and other ward staff satisfaction in using the proforma. Method This QIP was registered and approved by the Continuous Quality Improvement Team of Hull University Teaching Hospital NHS Trust. This was a prospective study with designed proforma for FY 1 doctors to be used following primary care centres referral to the Paediatric Surgery ward. Results There were 38 primary care referrals between 16th October 2022 and 20th December 2022 with 30 referrals from the GP surgeries and 8 referrals from the Urgent Care centres. The overall satisfaction was excellent with the use of the designed proforma by the FY 1 doctors and other ward and we had 100% completion in filling in the designed proforma. Conclusions A well designed referral proforma could improve the confidence and quality of referral documentation from primary care centres by FY 1 doctors.

Facilitating person‐centred care: integrating an electronic client feedback tool into continuous quality improvement processes to deliver client‐responsive HIV services in the Democratic Republic of Congo

AbstractIntroductionEngaging communities in the design, implementation and monitoring of health services is critical for delivering high‐quality, person‐centred services that keep people living with HIV engaged in care. The USAID‐funded Integrated HIV/AIDS Project in Haut‐Katanga (IHAP‐HK) integrated an electronic client feedback tool into continuous quality improvement (CQI) processes. We aimed to demonstrate this system's impact on identifying and improving critical quality‐of‐care gaps.MethodsThrough stakeholder and empathy mapping, IHAP‐HK co‐designed a service quality monitoring system—comprising anonymous exit interviews and ongoing monitoring through CQI cycles—with people living with HIV, facility‐based providers and other community stakeholders. IHAP‐HK trained 30 peer educators to administer oral, 10‐ to 15‐minute exit interviews with people living with HIV following clinic appointments, and record responses via the KoboToolbox application. IHAP‐HK shared client feedback with facility CQI teams and peer educators; identified quality‐of‐care gaps; discussed remediation steps for inclusion in facility‐level improvement plans; and monitored implementation of identified actions. IHAP‐HK tested this system at eight high‐volume facilities in Haut‐Katanga province from May 2021 through September 2022.ResultsFindings from 4917 interviews highlighted wait time, stigma, service confidentiality and viral load (VL) turnaround time as key issues. Solutions implemented included: (1) using peer educators to conduct preparatory tasks (pre‐packaging and distributing refills; pulling client files) or escort clients to consultation rooms; (2) limiting personnel in consultation rooms during client appointments; (3) improving facility access cards; and (4) informing clients of VL results via telephone or home visits. Due to these actions, between initial (May 2021) and final interviews (September 2022), client satisfaction with wait times improved (76% to 100% reporting excellent or acceptable wait times); reported cases of stigma decreased (5% to 0%); service confidentiality improved (71% to 99%); and VL turnaround time decreased (45% to 2% informed of VL results 3 months after sample collection).ConclusionsOur results showed the feasibility and effectiveness of using an electronic client feedback tool embedded in CQI processes to collect client perspectives to improve service quality and advance client‐responsive care in the Democratic Republic of Congo. IHAP‐HK recommends further testing and expansion of this system to advance person‐centred health services.

Caring for the whole person: transgender-competent HIV pre-exposure prophylaxis as part of integrated primary healthcare services in Vietnam.

IntroductionAlthough HIV prevalence among transgender women who have sex with men in Vietnam is high (16–18%), uptake of pre‐exposure prophylaxis (PrEP) is low compared to other populations. When PrEP was initiated in 2017, gender‐affirming healthcare was largely unavailable. Lack of access to competent, stigma‐free healthcare is a well‐documented barrier to transgender women's uptake of PrEP and primary healthcare (PHC). We aimed to demonstrate the utility of a PrEP quality improvement intervention in pinpointing and addressing barriers to PrEP use among transgender women in Vietnam.MethodsWe applied a real‐world participatory continuous quality improvement (CQI) and Plan‐Do‐Study‐Act (PDSA) methodology to ascertain barriers to PrEP uptake among transgender women and determine priority actions for quality improvement. A CQI team representing transgender women leaders, key population (KP)‐clinic staff, public‐sector HIV managers and project staff applied PDSA to test solutions to identified barriers that addressed the primary quality improvement outcome of the monthly change in PrEP uptake among transgender women and secondary outcomes, including month‐3 PrEP continuation, the impact of offering PHC on PrEP uptake and unmet PrEP need. We utilized routine programmatic data and a descriptive cross‐sectional study enrolling 124 transgender women to measure these outcomes from October 2018 to September 2021.ResultsFive key barriers to PrEP uptake among transgender women were identified and corresponding solutions were put in place: (1) offering gender‐affirming care training to KP‐clinics and community‐based organizations; (2) integrating gender‐affirming services into 10 KP‐clinics; (3) offering PHC through five one‐stop shop (OSS) clinics; (4) implementing a campaign addressing concerns related to hormone use and PrEP interactions; and (5) developing national HIV and transgender healthcare guidelines. New PrEP enrolment and month‐3 PrEP continuation increased significantly among transgender women. Of 235 transgender women who initially sought healthcare other than PrEP at OSS clinics, 26.4% subsequently enrolled in PrEP. About one‐third of transgender women reported unmet PrEP need, while two‐thirds indicated an interest in long‐acting cabotegravir.ConclusionsOffering gender‐competent, integrated PHC can increase PrEP enrolment and continuation, and can be an entry‐point for PrEP among those seeking care within PHC clinics. More work is needed to expand access to transgender women‐led and ‐competent healthcare in Vietnam.

Continuous quality improvement as a tool to implement evidence-informed problem solving: experiences from the district and health facility level in Uganda

BackgroundContinuous quality improvement processes in health care were developed for use at health facility level, and that is where they have been used the most, often addressing defined care processes. However, in different settings different factors have been important to support institutionalization. This study explores how continuous quality improvement processes were institutionalized at the district level and at the health facility level in Uganda.MethodsThis qualitative study was carried out in seven districts in Uganda. Semi-structured interviews with key informants from the district health management teams and document review were conducted. Thematic analysis was used to analyze the data.ResultsAll districts that participated in the study formed Continuous Quality Improvement (CQI) teams both at the district level and at the health facilities. The district CQI teams comprised of members from different departments within the district health office. District level CQI teams were mandated to take the lead in addressing management gaps and follow up CQI activities at the health facility level. Acceptability of quality improvement processes by the district leadership was identified across districts as supporting the successful implementation of CQI. However, high turnover of staff at health facility level was also reported as a detrimental to the successful implementation of quality improvement processes. Also the district health management teams did not engage much in addressing their own roles using continuous quality improvement.ConclusionThe leadership and management provided by the district health management team was an important factor for the use of Continuous Quality Improvement principles within the district. The key roles of the district health team revolved around the institutionalisation of CQI at different levels of the health system, monitoring results of continuous quality improvement implementation, mobilising resources and health care delivery hence promoting the culture of quality, direct implementation of CQI, and creating an enabling environment for the lower-level health facilities to engage in CQI. High turnover of staff at health facility level was also reported as one of the challenges to the successful implementation of continuous quality improvement. The DHT did not engage much in addressing gaps in their own roles using continuous quality improvement.

WaSH CQI: Applying continuous quality improvement methods to water service delivery in four districts of rural northern Ghana.

Continuous, safely managed water is critical to health and development, but rural service delivery faces complex challenges in low- and middle-income countries (LMICs). We report the first application of continuous quality improvement (CQI) methods to improve the microbial quality of household water for consumption (HWC) and the functionality of water sources in four rural districts of northern Ghana. We further report on the impacts of interventions developed through these methods. A local CQI team was formed and trained in CQI methods. Baseline data were collected and analyzed to identify determinants of service delivery problems and microbial safety. The CQI team randomized communities, developed an improvement package, iteratively piloted it in intervention communities, and used uptake survey data to refine the package. The final improvement package comprised safe water storage containers, refresher training for community WaSH committees and replacement of missing maintenance tools. This package significantly reduced contamination of HWC (p<0.01), and significant reduction in contamination persisted two years after implementation. Repair times in both intervention and control arms decreased relative to baseline (p<0.05), but differences between intervention and control arms were not significant at endline. Further work is needed to build on the gains in household water quality observed in this work, sustain and scale these improvements, and explore applications of CQI to other aspects of water supply and sanitation.

Facilitation of Surgical Innovation: Is It Possible to Speed the Introduction of New Technology While Simultaneously Improving Patient Safety?

To review efficiency metrics and patient safety data before and after implementation of a structured review process for surgical innovations. Surgical innovation ranges from minor incremental improvement to radical experimentation. Although innovation paradigms have been described, these are not widely adopted or enforced in the surgical community. A Continuous Quality Improvement Team (CQIT) of surgical quality officers and perioperative nurses was organized to perform structured reviews of proposed new surgical devices and procedures at a large quaternary cancer care center. The CQIT process was placed to precede an established Value Analysis Team business evaluation. Pre- and post-CQIT implementation metrics of approval process efficiency and patient safety data were compared. Seven novel procedures were also vetted by the CQIT. Forty-six product requests were evaluated after CQIT implementation. Compared with 34 products evaluated prior to CQIT establishment, the total mean evaluation time decreased from 124 to 51 days (P= 0.007). For new devices requiring intraoperative trial, the time between product proposal and trial decreased from a mean of 260 to 99 days (P= 0.014). The rate of device-related complications in the pre-CQIT group was 10% compared with 0% post-CQIT. Two devices, which administratively bypassed CQIT review, had both minor and major complications, including a mortality. Five novel procedures approved by CQIT with simulation were performed without complications. Using novel algorithms, the addition of a dedicated team of surgical quality officers to the surgical innovation evaluation process improved both the efficiency and the safety associated with introducing new devices and procedures into practice.

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 &lt;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 &lt;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.

Measuring team factors thought to influence the success of quality improvement in primary care: a systematic review of instruments

BackgroundMeasuring team factors in evaluations of Continuous Quality Improvement (CQI) may provide important information for enhancing CQI processes and outcomes; however, the large number of potentially relevant factors and associated measurement instruments makes inclusion of such measures challenging. This review aims to provide guidance on the selection of instruments for measuring team-level factors by systematically collating, categorizing, and reviewing quantitative self-report instruments.MethodsData sources: We searched MEDLINE, PsycINFO, and Health and Psychosocial Instruments; reference lists of systematic reviews; and citations and references of the main report of instruments. Study selection: To determine the scope of the review, we developed and used a conceptual framework designed to capture factors relevant to evaluating CQI in primary care (the InQuIRe framework). We included papers reporting development or use of an instrument measuring factors relevant to teamwork. Data extracted included instrument purpose; theoretical basis, constructs measured and definitions; development methods and assessment of measurement properties. Analysis and synthesis: We used qualitative analysis of instrument content and our initial framework to develop a taxonomy for summarizing and comparing instruments. Instrument content was categorized using the taxonomy, illustrating coverage of the InQuIRe framework. Methods of development and evidence of measurement properties were reviewed for instruments with potential for use in primary care.ResultsWe identified 192 potentially relevant instruments, 170 of which were analyzed to develop the taxonomy. Eighty-one instruments measured constructs relevant to CQI teams in primary care, with content covering teamwork context (45 instruments measured enabling conditions or attitudes to teamwork), team process (57 instruments measured teamwork behaviors), and team outcomes (59 instruments measured perceptions of the team or its effectiveness). Forty instruments were included for full review, many with a strong theoretical basis. Evidence supporting measurement properties was limited.ConclusionsExisting instruments cover many of the factors hypothesized to contribute to QI success. With further testing, use of these instruments measuring team factors in evaluations could aid our understanding of the influence of teamwork on CQI outcomes. Greater consistency in the factors measured and choice of measurement instruments is required to enable synthesis of findings for informing policy and practice.

Continuous quality improvement in AIDSRelief supported HIV treatment clinics in Uganda: An evaluation of “See-Try-Observe-Continue” (STOC) model in patient care

Aim: To evaluate the effectiveness of the STOC model for continuous quality improvement in improving patient care in two AIDSRelief (AR) HIV treatment facilities in Uganda Methods: In the initial stages, health workers in 17 AIDS Relief HIV treatment facilities were trained in continuous quality improvement (CQI). Consequently, the health workers built CQI teams and used a See Try Observe Continue (STOC) model adapted from the Plan Do Study Act (PDSA) approach to improve gaps identified for change and evaluated their success. A simple excel tracking tool was developed to follow up on the progress of the use of paediatric pharmacy order forms in Bushenyi Medical Centre (BMC) as well as missed ARV pick up in Kabarole hospital. Both descriptive and graphical findings were recorded during the pre and post follow ups. Results: The different clinics implemented at least one cycle of STOC for specific problems and registered improvements in patient care. At BMC, there was an improvement of usage of the paediatric pharmacy order forms from 50% of the paediatric patients seen in each month as well as improved recording of children's weight and height, parameters crucial in growth monitoring. There was a significant reduction in number of patients who missed picking their ARVs from 28/1000 in Month 1 to 5/1000 in month 7 to 1/1000 patients in month 10. Conclusion: STOC model encourages and enhances evidence-based practices in the AR clinics. CQI activities enhanced by implementation of STOC to improve identified gaps at the facilities are imperative to achieving effective patient care.

Implementing Continuous Quality Improvement Process in Potassium Management in Peritoneal Dialysis Patients

Abnormal plasma potassium levels are not uncommon in peritoneal dialysis (PD) patients. Here, we implemented a continuous quality improvement (CQI) approach that mainly focused on dietary management to improve potassium control in PD patients. All clinically stable patients who visited the PD clinic monthly were included in this study. A CQI team that included nephrologists, primary nurses, dietician, patients, and their family members was organized, and it monitored patients for 6 months. Patients were asked to provide their dialysis records and 3-day dietary records at each visit. Dialysis adequacy, including potassium and phosphorus removals, was checked before and after the implementation of CQI. Changes in dietary prescription, without altering dialysis prescriptions and potassium supplementation, were made monthly, according to patients' dietary information and blood potassium levels. In total, 84 patients (28 male and 56 female) were included in this study. At baseline, the prevalence of hyperkalemia and hypokalemia was 14.3% each. After the intervention, the prevalence of hyperkalemia dropped to 10.7% and 6% at 3 months and 6 months, respectively. The prevalence of hypokalemia dropped to 8.3% and 7.1% at 3 months and 6 months, respectively. Our data suggest that implementing CQI, with a focus on dietary intervention, could significantly reduce the prevalence of potassium abnormality in PD patients.

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"

Individuals with serious mental illness often are unable to access consumer- and family-oriented community care, resulting in repeated hospitalizations, incarceration, and homelessness. The "medical home" concept was developed in primary care to provide accessible and accountable services for individuals with chronic medical conditions. Building on the work done in primary care, the authors propose a "mental health home." The model of care incorporates medical home characteristics, such as access to and coordination of services, integration of primary and preventive care, adoption of recovery orientation and evidence-based practices, and family and community outreach. Barriers to and strategies for implementation of mental health homes are discussed.

This Month in Anesthesiology

This Month in Anesthesiology

A new approach to classifying malnutrition in the hemodialysis patient

Background: Novel classification nomenclature defining the type of malnutrition by the root cause of the hypoalbuminenia has been developing in the literature since 1999. As the classification of malnutrition became more definite in the literature, the need to assess the type of malnutrition, thereby the root cause(s) and initiate appropriate intervention(s), has become apparent. Methods: In September 1999, San Diego Dialysis began a continuous quality improvement (CQI) project to assess the root causes of hypoalbuminemia for patients with serum albumin level <3.5 g/dL. An extensive review of the literature was conducted on the subject of malnutrition, inflammation, and the acute-phase reaction. Findings: Two major groups of patients emerged: those consuming adequate protein and calories, yet presenting with hypoalbuminemia, and those suffering from a protein calorie deficit. Observation of the second group showed that although the monthly percentage of patients with hypoalbuminemia remained fairly constant, the names on the list changed from month to month. Conclusions: The CQI team developed a protocol and a unique nomenclature to classify the types of malnutrition, type I, type IIa, type IIb, or mixed, by adapting the definitions in the literature through clinical practice. Interventions were developed to address each classification of malnutrition. © 2002 by the National Kidney Foundation, Inc.

Pediatric hemodialysis and peritoneal dialysis: Report rewards program

FOR PEDIATRIC renal dietitians, nutrition education and compliance with diets and medications can be a challenge. One of the most challenging groups is adolescents. They typically have a need for “acceptance” from their peer group. In addition, independence issues arise and risk-taking behaviors are common. Moreover, food choices prove problematic. For example, what is an adolescent’s favorite food? Hamburgers, pizza, tacos, fried chicken, and french fries are typical answers. These are foods that we dietitians normally cringe at when we hear them in a diet recall, but they are a staple for renal teens. Adolescents feel the pressure to eat certain foods to fit in, and this includes consuming these nonkidney friendly items. In addition, teens typically avoid taking medications such as phosphorus binders. To motivate our renal kids and teens to improve compliance, DaVita Children’s Dialysis Center Continuous Quality Improvement team developed the rewards program “You Deserve an A . . . ,” which is focused this quarter on phosphorus control. We chose to begin the program in August 2001 to coincide with going back to school and tap into the excitement the children feel about the start of the academic year. Similar to the start of the school year, the “You Deserve an A . . . ” rewards program starts patients off with a clean slate. An “A” is earned if there is a 10% improvement from the previous laboratory value and/or the patient is within the normal laboratory value for their age. For each “A” that is earned, prizes are awarded (pencils, pens, folders, and so on). At the end of the quarter, a rewards party is held with recognition and prizes awarded according to the following categories: Top of the Class (earned 4 As), Honor Roll (3 As), Halfway there (2 As), and Needs Improvement (1 A). Importantly, if the patient does not meet the monthly goal, they earn a score of “I” or incomplete. The interdisciplinary team discusses ways to help improve with every patient. A variety of techniques are used for this effort, including the following:

Medication error identification is a key to prevention: a performance improvement approach.

The leadership of Memorial Hospital of Carbondale sponsored an interdisciplinary continuous quality improvement team effort to address medication errors. The need for increased awareness, documentation, and reporting of medication errors throughout the organization was identified as a priority through risk assessment. Ineffective reporting of medication errors occurred in all medication distribution categories: prescribing, transcribing, dispensing, and administration. Improvement interventions focused on building an awareness of the occurrence of medication errors through identification and on the reporting of those errors to the risk management department.

The relationship between continuous quality improvement and research.

The adoption of new care processes can take years despite high-quality research findings that support the change in clinical practice. Healthcare quality professionals, with their leadership and continuous quality improvement (CQI) skills, are critical champions in accelerating and supporting the change toward evidence-based practice. Heightened attention to the relationship between CQI, research, and research utilization is vital. This article addresses CQI strategies and research activities that can help organizations advance quality of care and patient outcomes. By broadening their repertoire of CQI methods, healthcare quality professionals can provide more value to their organizations and expand the complex problems and projects that CQI teams can manage.

Improving Serum Albumin Levels in Hemodialysis Patients by a Continuous Quality Improvement Project

Protein nutrition and serum albumins predict present and future mortality and morbidity. The North East Albuquerque Dialysis Center undertook a quality improvement project to improve serum albumin levels in hemodialysis patients. The dialysis facility's quality assurance team evolved into a continuous quality improvement team just before this project. The timeline and steps in this evolution are presented. The continuous quality improvement project process analysis, interventions, and outcome rates are also described. The project has resulted in a rate of less than or equal to 10% of hemodialysis patients with serum albumins less than 3.4 for the past 3 years.

Continuous Quality Improvement Project: Decreasing the Potential for the Development in the Inpatient Setting of Drug Resistance by Improving Nursing Practice for HAART Administration

HIV/AIDS patients' dissatisfaction with highly active antiretroviral therapy (HAART) medication administration in the inpatient setting was the impetus for a continuous quality improvement (CQI) project. The purpose of the CQI project was to initiate a change in nursing practice for HAART medication administration. The goal of the project was to decrease the potential for development of drug resistance in the inpatient setting related to nonadherence with food requirements for drug administration and to incomplete or "missed" doses of prescribed HAART. A secondary goal was to increase the provision of patient education on HAART medications by nurses. The interdisciplinary CQI team found that medication administration in the inpatient setting involved more than nurses simply "passing meds." Inpatient medication administration was a complex process involving a variety of hospital systems, departments, and traditions, all of which had an impact on patient care. The article describes the CQI methodology that was used for the project and how each step of the project was planned and implemented. Specific problems related to administering HAART in the hospital setting are listed as areas for needed nursing research.

Continuous quality improvement efforts decrease postoperative ileus rates.

This article describes a continuous quality improvement team's efforts to reduce the number of patients at risk for developing a postoperative ileus. This study was limited to patients who underwent a surgical procedure that did not involve the bowel. Patients who developed an ileus after the surgical procedure (study group) were compared with patients who did not develop an ileus after the same procedure (control group). Principal factors associated with a postoperative ileus included a low serum albumin level, excessive use of narcotics, and a history of a previous gastrointestinal condition. Practice changes were made as a result of these findings. A follow-up chart review revealed a decrease in the postoperative ileus rate.