Culture Of Continuous Quality Improvement Research Articles

Using Patient Navigation to Reduce Time to Diagnosis of Breast Cancer in Uganda

PurposeThe Ugandan Ministry of Health adopted BI-RADS as standard of care in 2016. The authors performed a medical audit of breast ultrasound practices at four tertiary-level hospitals to assess interpretive performance. The authors also determined the effect of a low-cost navigation program linking breast imaging and pathology on the percentage of patients completing diagnostic care. MethodsThe authors retrieved 966 consecutive diagnostic breast ultrasound reports, with complete data, for studies performed on women aged >18 years presenting with symptoms of breast cancer between 2018 and 2020 from participating hospitals. Ultrasound results were linked to tumor registries and patient follow-up. A medical audit was performed according to the ACR’s BI-RADS Atlas, fifth edition, and results were compared with those of a prior audit performed in 2013. At Mulago Hospital, an intervention was piloted on the basis of patient navigation, cost sharing, and same-day imaging, tissue sampling, and pathology. ResultsIn total, 888 breast ultrasound examinations (91.9%) were eligible for inclusion. Compared with 2013, the postintervention cancer detection rate increased from 38 to 148.7 cancers per 1,000 examinations, positive predictive value 2 from 29.6% to 48.9%, and positive predictive value 3 from 62.7% to 79.9%. Specificity decreased from 90.5% to 87.7% and sensitivity from 92.3% to 81.1%. The mean time from tissue sampling to receipt of a diagnosis decreased from 60 to 7 days. The intervention increased the percentage of patients completing diagnostic care from 0% to 100%. ConclusionsEfforts to establish a culture of continuous quality improvement in breast ultrasound require robust data collection that links imaging results to pathology and patient follow-up. Interpretive performance met BI-RADS benchmarks for palpable masses, except sensitivity. This resource-appropriate strategy linking imaging, tissue sampling, and pathology interpretation decreased time to diagnosis and rates of loss to follow-up and improved the precision of the audit.

Assessing the Perception of Family and Caregivers' Experience with Mental Health and Substance Use Services.

Standardized client feedback surveys encourage a culture of continuous quality improvement, allow for comparison of results over time and across similar types of service providers, and encourage use of evidence-based practices. Recognizing the importance of family and other caregivers in supporting people accessing services for mental health and substance use challenges, a standardized perception-of-care tool (the Ontario Perception of Care Tool for Mental Health and Addictions, OPOC-MHA) was adapted to collect feedback specific to the caregiver experience with these services. A collaborative process engaged a broad range of mental health and/or addiction providers, family advisory networks, and family members and caregivers to identify themes, specific items, and implementation approaches. The final version of the tool evolved through an iterative process of pilot testing and stakeholder feedback. Family member and caregiver perceptions of care will identify service areas in need of improvement, contribute to quality improvement initiatives, and facilitate the comparison of findings over time.

Kaizen Process Improvement in Radiology: Primer for Creating a Culture of Continuous Quality Improvement.

Kaizen process improvement is an element of lean production that is an approach to creating continuous improvement. Kaizen is based on the idea that small ongoing positive changes in workflow and elimination of waste can yield major improvements over time. A focused Kaizen event, or rapid process improvement event, can lead to sustainable process improvement in health care settings that are resistant to change. This approach has been proven to be successful in health care. These events are led by a trained facilitator and coach who provides appropriate team education and engagement. To ensure success, the team must embrace the Kaizen culture, which emphasizes the development of a "learning organization" that is focused on relentless pursuit of perfection. The culture empowers all staff to improve the work they perform, with an emphasis on the process and not the individual. Respect for individual people is key in Kaizen. In radiology, this method has been successful in empowering frontline staff to improve their individual workflows. A 5-day Kaizen event has been successful in increasing on-time starts, decreasing lead time, increasing patient and staff satisfaction, and ensuring sustainability. Sustainable success can occur when the team stays true to lean principles, engages leaders, and empowers team members with the use of timely data to drive decision making. Online supplemental material is available for this article. ©RSNA, 2022.

Building a culture of continuous quality improvement in an acute trust

Purpose: At the start of this work there was no visibility or organisation approach to quality improvement (QI). This resulted in missed opportunities to optimise the benefits of improvement work and share learning across the organisation.

Evaluation of Engineering Students’ Learning Outcomes: Creating a Culture of Continuous Quality Improvement

Assessment and evaluation of outcomes and continuous quality improvement often lead to uneasiness among engineering educators, which is a barrier to implementing an effective system of results-assessment. The sophisticated evaluation models and analytical instruments adopted by higher learning institutions are believed to worsen this uneasiness, impeding the successful implementation of programme quality improvement. In this paper, the challenges in assessing and evaluating learning outcomes, types of programme outcome assessment model and an analytical tool known as Engineering Outcome Analytics developed by Tunku Abdul Rahman University College for the assessment were presented. Documents related to quality improvement from two higher learning institutions in Malaysia were reviewed and discussed based on the key elements of continuous quality improvement. The results can be used to avoid the shortcomings and adopt the best practices in continuous quality improvement. With proper understanding on the key elements of continuous quality improvement, and adoption of culminating assessment model and a highly integrated analytical tool, engineering educators and programme owners are expected to benefit from this re-search in three ways. First, it cultivates a culture of continuous improvement of quality by increasing the educators' willingness to evaluate results. Second, it enhances their existing analytical tools to reflect students' actual developments, resulting in significant continuous actions to improve quality. Third, it satisfies the accreditation requirements on outcomes-based assessment.

Management Systems to Structure Continuous Quality Improvement.

This review describes the processes and effectiveness of the primary management systems that structure and sustain consistent behaviors and result in a transformed culture of continuous quality improvement (CQI) from top to bottom throughout the Henry Ford medical laboratory enterprise. Through a 17-year focus to achieve a functional CQI enterprise, quality management systems were developed and continuously improved by teams of laboratory leaders, managers, and quality specialists to coordinate and standardize human efforts, and provide actionable knowledge and data to engage improvement efforts at all levels of work. Lean and ISO 15189 discipline and requirements were addressed in annual management review of functionality and effectiveness to close gaps and further refine the management systems. Improvements in the use and effectiveness of 4 management systems are illustrated. The 4 primary management systems that provide structure and support transformation to a culture of CQI are the team leader, Plan-Do-Check-Act problem-solving, deviation management, and daily management systems. These management systems are designed to deepen the effectiveness of the continuous improvement culture by helping managers understand variation in the work they oversee and providing guidance for more effective employee engagement in the daily processes of quality improvement.

Laboratory Process Improvement: A Quality Initiative in an Outpatient Oncology Clinic.

The goal of achieving maximum productivity through process redesign and teamwork in oncology laboratory (lab) operations can be challenging in cancer care organizations. At an urban cancer center, missing lab orders occurred frequently and led to increases in lab errors, turnaround time, and patient wait times. Patient and staff satisfaction metrics were also affected, resulting in suboptimal scores. A nurse-driven practice change project was initiated after a thorough assessment in two clinic sites. The application of targeted lean methodology to redesign lab processes and workflows, in addition to engaging multiple stakeholders, was implemented to support a culture of continuous quality improvement.

CPD article: Quality improvement, checklists and systems of work: why do we need them?

Missing out one small step in a complex procedure can lead to an error. A checklist is a list of actions that can identify the small but crucial steps which may be missed out. Checklists are just one of the tools used to form a culture of continuous quality improvement (QI) in veterinary practice. QI is about understanding the level of care practices provide and implementing interventions to try to improve it. Checklists have been used in aviation and in human healthcare to reduce errors. The use of a surgical safety checklist can be very effective both in human healthcare and in veterinary practice. Checklists can be used in many other areas of practice too. They are a patient safety system, not just a piece of paper, they encourage teamwork, communication and situational awareness and can help to reduce errors

Fostering trust, collaboration, and a culture of continuous quality improvement: A call for transparency in medical school accreditation.

Medical schools provide the foundation for a physician’s growth and lifelong learning. They also require a large share of government resources. As such, they should seek opportunities to maintain trust from the public, their students, faculty, universities, regulatory colleges, and each other. The accreditation of medical schools attempts to assure stakeholders that the educational process conforms to appropriate standards and thus can be trusted. However, accreditation processes are poorly understood and the basis for accrediting authorities’ decisions are often opaque.We propose that increasing transparency in accreditation could enhance trust in the institutions that produce society’s physicians. While public reporting of accreditation results has been established in other jurisdictions, such as Australia and the United Kingdom, North American accrediting bodies have not yet embraced this more transparent approach. Public reporting can enhance public trust and engagement, hold medical schools accountable for continuous quality improvement, and can catalyze a culture of collaboration within the broader medical education ecosystem. Inviting patients and the public to peer into one of the most formative and fundamental parts of their physicians’ professional training is a powerful tool for stakeholder and public engagement that the North American medical education community at large has yet to use.

Quality improvement, checklists and systems of work: why do we need them?

Missing out one small step in a complex procedure can lead to an error. A checklist is a list of actions that can identify the small but crucial steps which may be missed out. Checklists are just one of the tools used to form a culture of continuous quality improvement (QI) in veterinary practice. QI is about understanding the level of care practices provide and implementing interventions to try to improve it. Checklists have been used in aviation and in human healthcare to reduce errors. The use of a surgical safety checklist can be very effective both in human healthcare and in veterinary practice. Checklists can be used in many other areas of practice too. They are a patient safety system, not just a piece of paper, they encourage teamwork, communication and situational awareness and can help to reduce errors.

Sequential third-year medical student quality assurance (QA) clerkship projects appear to introduce a culture of continuous quality improvement across New Jersey family medicine practices

BackgroundIn recent years, Rutgers New Jersey Medical School Department of Family Medicine has integrated a quality assurance (QA) project as a required component of their 5-week medical student clerkship. This...

Integration of Continuous Quality Improvement Methods Into Annual Program and Institutional Evaluation.

The Accreditation Council for Graduate Medical Education's Next Accreditation System requires continuous program improvement as part of program evaluation for residency training institutions and programs. To improve the institutional- and program-level evaluation processes, to operationalize a culture of continuous quality improvement (CQI), and to increase the quality and achievement of action items, the Wayne State University Office of Graduate Medical Education (WSU GME) incorporated CQI elements into its program evaluation process. Across 4 academic years, WSU GME phased the following 4 CQI elements into the evaluation process at the program and institutional levels, including the annual program evaluation (APE) and the annual institutional review: (1) An APE template; (2) SMART (specific, measurable, accountable, realistic, timely) format for program and institutional goals; (3) Dashboard program and institutional metrics; and (4) Plan-do-study-act cycles for each action item. Action item goals improved in adherence to the SMART format. In 2014, 38% (18 of 48) omitted at least 1 field, compared with 0% omitting any fields in 2018. More complete action items took less time to resolve: 1.7 years compared with 2.4 years (t (43.3) = 2.87, P = .003). The implementation of CQI in the APE was well received by program leadership. After leveraging CQI methods, both descriptions of institutional- and program-level goals and the time required for their achievement improved, with overall program director and program coordinator satisfaction.

Clinical Referral Laboratory Personnel's Perception of Challenges and Strategies for Sustaining the Laboratory Quality Management System.

ObjectivesTo explore challenges explaining the decrease in quality performance and suggest strategies to improve and sustain laboratory quality services.MethodsTwenty key informants’ interviews from laboratory personnel were conducted in five laboratories. Four had previously shown a decrease in quality performance. Interviews were transcribed verbatim and analyzed using inductive thematic analysis.ResultsTwo themes emerged: (1) insufficient coordination and follow-up system towards accreditation, where lack of coordination, follow-up, and audits explained the decrease in performance; (2) inadequate resource optimization, where insufficient knowledge in Laboratory Quality Management System (LQMS), ownership by laboratory workforce, and insufficient stakeholders’ communication contributed to low-quality performance.ConclusionsThe coordination, follow-up, and assessments of LQMS, in conjunction with training of laboratory workforce, would establish an institutional culture of continuous quality improvement (CQI) towards accreditation and sustainment of quality health care. To achieve CQI culture, routine gap checking and planning for improvement using a system approach is required.

Just Culture: Practical Implementation for Radiologist Peer Review

Peer review is a cornerstone of quality improvement programs and serves to support the peer learning process. Peer review in radiology incorporates the review of diagnostic imaging interpretation, interventional procedures, communication, and the evaluation of untoward patient events. A just culture is an environment in which errors and near-miss events are evaluated in a deliberately nonpunitive framework, avoiding a culture of blame and responsibility and focusing instead on error prevention and fostering a culture of continuous quality improvement. Adoption of a just culture requires careful attention to detail and relies on continuous coaching of individuals and teams to ensure future systems improvements and a culture of safety. The authors describe the practical implementation of a just culture framework for peer review in an academic radiology department and highlight its application to interpretive, noninterpretive, and procedural domains through case examples.

Focused Resident Education and Engagement in Quality Improvement Enhances Documentation, Shortens Hospital Length of Stay, and Creates a Culture of Continuous Improvement

System-based practice with an emphasis on quality improvement (QI) is a recent initiative for the American College of Surgeons and a core-competency for surgical trainees. Few surgical training programs have a curriculum for hospital-based QI. Our vascular surgery service implemented several QI initiatives focused on decreasing length of stay (LOS) by targeting resident education and engagement. Residents were educated on terminology and processes impacting hospital and CMS QI metrics such as Medicare geometric mean LOS (CMS GMLOS) and diagnostic-related groups (DRG) with complication or comorbidity (CC/MCC) coding. LOS initiatives focused on identifying, tracking and removing avoidable perioperative delays, and improving accuracy of clinical documentation. Residents were given specific roles in QI initiatives and the impact on LOS was quantified. Patients' CMS GMLOS were compared to actual LOS during daily rounds, with confirmation that resident progress notes contained thorough and accurate documentation of diagnoses, comorbidities, and complications. Ten minutes during weekly preoperative conferences were dedicated to ongoing QI, with LOS metrics for the inpatient census presented by trainees and reviewed by attendings. Feedback was given addressing barriers to avoidable delays and impact on LOS. Data for July 2016-June 2017 (FY17) was compared to preimplementation baseline data (FY16) for vascular discharges overall. Accurate documentation of acuity was evaluated with in-depth review of notes and overall case mix index. Within the first year of implementation, overall vascular admissions demonstrated a 21% reduction in LOS, closing the gap between observed LOS and expected CMS GMLOS, from 2.1days to 0.5days on average. Documentation improved, with a shift in 24% of DRGs to accurately reflect CC/MCC. Overall case mix index increased by 10%, from 3.07 to 3.37. A culture of continuous quality improvement can be created with the establishment of a QI infrastructure that educates and involves trainees as stakeholders. Assigning discrete roles to increase resident accountability supports both formal and informal resident education that can substantially impact hospital benchmarking metrics.

QUALITY ASSURANCE IN HIGHER EDUCATION: IMPLICATIONS FOR VIETNAMESE UNIVERSITIES

This papar presents the literature based research into the quality assurance practices in higher education. A framework consisting of five components - leadership and management, stakeholder engagement, internal processes, cooperation and collaboration, and culture of continuous quality improvement - will be presented. The study analyses these five components as the driving factors for quality assurance and quality improvement at the institutional level. Finally, the implications for Vietnamese higher education will be provided. Among these implications is the need to manage quality assurance as organisational change for sustainability.

Can you see what matters to me?

Introduction: As staff we only see a small part of our patient’s life. On face value we see that they come into hospital for management of their condition. What we don’t always see is what it means to the children and their families. That is, unless we ask. The Ambulatory Units at The Sydney Children’s Hospitals Network have undertaken a quality improvement project to bring visibility to “what matters to you” – using patient stories and an interactive white board to seek feedback from patients and families to co-design our services, make small but valuable changes, and drive cultural change within the teams. Methodology and Change Implemented: A co-design and quality improvement methodology was used to create collaboration between consumers and staff. Two approaches were tested: A large interactive whiteboard was placed in each unit to seek input from consumers on “what matters to you” Patient Stories – patients with chronic conditions and their family members were invited to write detailed accounts of what it means to them to attend the Hospital Aim: To test the use of interactive whiteboards and patient stories to ask “what matters to you” (an approach learned from international peers) to: Involve consumers in service design: Drive cultural change within the unit and create an environment of continuous quality improvement Highlights: Since implementation of this project twelve months ago – two cycles have been complete, involving: Large white board placed in the unit with an invitation to patients/families to write/draw their feedback Information/drawings were captured and responses recorded and themed Responses were transformed into quality improvement projects or small scale changes Actions undertaken were fed back to consumers on the Quality Board - “you said… we did” The whiteboard was cleared to commence a second round The interactive whiteboards increased conversations between consumers and staff, removing hierarchy and valuing consumer input. The culture change within the department was significant, with staff realising that the little things that matter can easily be applied to improve the patient experience. The patient written stories are being used to create one-page ‘what matters to me’ cards for each child. Feedback is also being incorporated into handover to make the ‘person’ more visible – such as “and Max enjoys chocolate milk with his infusion”. Sustainability and transferability: This project is a self-sustaining way of encouraging continuous consumer engagement. The boards have become a central piece of “wall art” which has led to staff valuing this component of their work. This initiative can easily be scaled and spread across all units and we have recently extended this initiative to the Outpatients Department. Conclusion and lessons learned: Using whiteboards as an interactive approach to invite consumer feedback has been an effective initiative in generating a culture of continuous quality improvement and service co-design. Three key lessons learned: Seemingly small changes can have big impacts Co-design doesn’t have to be formal Making the feedback board “wall art” can change the culture within the unit and bring visibility to what matters to patients/families

Creating a Culture of Continuous Quality Improvement: A Pilot of a Quality Team Huddle to Move Knowledge into Action within a Radiotherapy Treatment Program

Continuous quality improvement is the responsibility of all healthcare providers to ensure a positive experience and improved patient outcomes. Quality Conversations (QC) is a very short, weekly, huddle that provides a team building opportunity to discuss and act on quality improvement and safety opportunities, share ideas for what can be done differently and to celebrate accomplishments achieved together. We piloted these weekly QCs to understand the effectiveness of these conversations on a busy radiotherapy department. Multiple forums were engaged to raise awareness amongst the team with regards to, goals, purpose and benefits of engaging in these conversations. The huddles were held each week, for 15 minutes (maximum) in front of a board facilitated by a member(s) of the leadership team. All members of the planning team were encouraged to attend. Each conversation was grounded in three guiding questions: What are we currently working on? How well are we doing? Are our change ideas working? Staff were encouraged to discuss bright ideas and next steps and identify key participants in leading the change. The PDSA model was used to track and guide the quality improvement work. Change initiative leaders reported back at the following week's QC. Pre and post evaluations were administered to all members of the planning team to identify the strengths and opportunities of the QC approach. The non-validated web based survey included 11 five item Likert scale questions, and 2 open ended questions on value of QC and opportunities for sustaining QCs into practice. This pilot project suggests that a QC approach encouraged an open form for all staff to regularly discuss quality improvement initiatives and integrate recommendations into daily practice. Changing the frequency of huddles was an identified opportunity for improvement. Quality Conversations is an innovative idea that can increase team collaboration, and problem solving using performance data, patient outcomes and safety.

A review of national policies and strategies to improve quality of health care and patient safety: a case study from Lebanon and Jordan

BackgroundImproving quality of care and patient safety practices can strengthen health care delivery systems, improve health sector performance, and accelerate attainment of health-related Sustainability Development Goals. Although quality improvement is now prominent on the health policy agendas of governments in low- and middle-income countries (LMICs), including countries of the Eastern Mediterranean Region (EMR), progress to date has not been optimal. The objective of this study is to comprehensively review existing quality improvement and patient safety policies and strategies in two selected countries of the EMR (Lebanon and Jordan) to determine the extent to which these have been institutionalized within existing health systems.MethodsWe used a mixed methods approach that combined documentation review, stakeholder surveys and key informant interviews. Existing quality improvement and patient safety initiatives were assessed across five components of an analytical framework for assessing health care quality and patient safety: health systems context; national policies and legislation; organizations and institutions; methods, techniques and tools; and health care infrastructure and resources.ResultsBoth Lebanon and Jordan have made important progress in terms of increased attention to quality and accreditation in national health plans and strategies, licensing requirements for health care professionals and organizations (albeit to varying extents), and investments in health information systems. A key deficiency in both countries is the absence of an explicit national policy for quality improvement and patient safety across the health system. Instead, there is a spread of several (disjointed) pieces of legal measures and national plans leading to fragmentation and lack of clear articulation of responsibilities across the entire continuum of care. Moreover, both countries lack national sets of standardized and applicable quality indicators for performance measurement and benchmarking. Importantly, incentive systems that link contractual agreement, regulations, accreditation, and performance indicators are underutilized in Lebanon and absent in Jordan. At the healthcare organizational level, there is a need to instill a culture of continuous quality improvement and promote professional training in quality improvement and patient safety.ConclusionStudy findings highlight the importance of aligning policies, organizations, methods, capacities and resources in order to institutionalize quality improvement and patient safety practices in health systems. Gaps and dysfunctions identified can help inform national deliberations and dialogues among key stakeholders in each study country. Findings can also inform future quality improvement efforts in the EMR and beyond, with a particular emphasis on LMICs.

P037: The Ontario Emergency Department Return Visit Quality Program: a provincial initiative to promote continuous quality improvement

Introduction: Analyzing the charts of patients who have a return visit to an emergency department (ED) requiring hospital admission (termed ‘RV’) is an efficient way to identify adverse events (AEs). Investigating these AEs can inform efforts to improve the quality of care provided. The ED RV Quality Program (RVQP) is a new initiative supported by Ontario’s Ministry of Health and Long-Term Care and managed by Health Quality Ontario. It aims to promote a culture of continuous quality improvement through routine audit/investigation of RVs. Methods: The provincial program is mandatory for high-volume EDs and requires auditing of some 72-hour RVs and all 7-day RVs involving ‘sentinel diagnoses’ (subarachnoid hemorrhage [SAH], acute myocardial infarction [AMI], or pediatric sepsis [PS]). A standardized audit template is followed that includes assessment of the type/severity and underlying causes of AEs, and potential actions for improvement. Results: 73 high-volume EDs and 16 smaller EDs (collectively receiving 90% of all ED visits in Ontario) are participating in the program. Nine months’ data have been released to date, comprising 33,956 RVs (1.05% of 3,235,751 ED visits). Of these, 233 RVs (0.69%) were for a sentinel diagnosis (SAH=11, AMI=191, PS=31). The most common presenting complaint on the index visit was abdominal pain (18%). The most common discharge diagnosis following RV admission was acute appendicitis (3.8%). Conclusion: The ED RVQP aims to improve the quality of care provided in Ontario’s EDs by requiring hospitals to conduct audits of RVs and plan actions for improvement when quality gaps are identified. Participating hospitals have completed hundreds of audits to date.