Quality Management Department Research Articles

Klinischer Behandlungspfad für die Mammachirurgie: Pfadcontrolling und Effekte

PURPOSE: The introduction of a DRG-based case fee system in Germany has required a rethinking of the design of patient treatments with the goal of providing high quality treatment while ensuring that the costs of treatment are covered. The aim of this study was to examine the effectiveness of implementing a clinical pathway in breast surgery. Parameters for this were the duration of in-hospital stay and cost trends. Additional objectives included an analysis of pathway monitoring and the further development of the clinical pathway. METHOD: After an analysis of the current situation and the target state, the Interdisciplinary Breast Center of Charite Berlin together with the Central Quality Management Department developed a clinical pathway, which included contributions by all specialists involved. After implementation of the clinical pathway, the impact for the years 2006 and 2007 was evaluated with regard to in-hospital stay, the number of cases, and the total cost per case, and pathway monitoring was carried out. RESULTS: After implementation of the clinical pathway, the mean in-hospital stay decreased by 17.7 % and the total cost of treatment per case sank by 23.4 % in 2007, compared to 2006 prior to implementation of the pathway. The introduction of the clinical pathway, to which all specialists involved had contributed, led to a significant reorganization of in-hospital operative care processes for the treatment of women with breast cancer. CONCLUSION: The introduction of clinical pathways can lead to a decrease in in-hospital stay and in the total cost per case through the standardization of processes and times. The implementation of a clinical pathway results in an optimization of the in-hospital course of treatment.

Stop the pain! A nation-wide quality improvement programme in paediatric oncology pain control

Introduction Little is known about the impact of translation of pain management clinical practice guidelines on pain control in paediatrics. In an effort to overcome this, a longitudinal, nation-wide, multi-centre paediatric quality improvement (QI) study was initiated by the German Society of Pediatric Haematology and Oncology (GPOH) entitled Schmerz-Therapie in der Onkologischen Paediatrie (STOP). Objective The project’s primary major aims were to improve paediatric oncology pain control in Germany, and to evaluate the project’s impact on the pain management quality. To achieve these aims, STOP encompassed six sequential phases to evaluate present practice, develop recommendations for practical pain control, actively engage participants in improvement strategies, and assess change. The purpose of this paper is to briefly describe STOP in its entirety, report on comparisons between active quality management (QM) departments that actively participated in the project and non-active QM departments regarding differences in pain control, patients’ and parents’ perspectives on pain control and health professionals’ knowledge, and to discuss the impact of STOP as a whole. Methods Four hypotheses were examined: (1) changes in health care professionals’ knowledge on pain in paediatric oncology and pain management after a three-year period (2) impact of active participation in the STOP-project; (3) differences in patients’ and parents’ perspective in active QM versus non-active QM departments; (4) impact of the STOP-project on the health care professionals’ knowledge in active QM versus non-active QM departments. Data included surveys, interviews, and standardised pre-/post-intervention documentation of pain control. All German paediatric oncology departments were invited to participate. The prime means of intervention was education (printed material, passive participation; additional lectures and feed-back, active participation). Quality indicators were defined and compared with regards to the four hypotheses. Results Sixty-eight departments participated passively. Eight departments participated actively, enrolling 224 patients (median age, 9 years) and documenting a total of 2265 treatment days. In the areas addressed, all health professionals demonstrated increases in knowledge on pain and pain control after a three-year period. STOP objectively improved pain control in the actively participating departments. Painful modes of drug administration were used less frequently; the usage of mixed opioid agonists-antagonists was reduced; the physicians’ knowledge of the treatment of neuropathic pain increased; pain ratings significantly decreased, and less episodes of strong pain were observed. There was a significant increase in the proportion of health-care professionals who post-interventionally judged that pain therapy had been initiated earlier and at exactly the right time. Neither patients nor parents felt, however, that there was any quality improvement. According to participants’ self-assessment, STOP improved practical pain management in actively participating departments, while in passively participating departments the change to the better was negligible. Conclusion STOP predominantly aimed at and succeeded in the improvement of structure, process and outcome quality. With regard to patients’ and parents’ opinions, the interview tools might have been unsuited to measure the quality of pain control, or STOP was insufficient to improve pain control to a magnitude significant to the patient.

Developing the Infrastructure to Support EBP: It Takes a Library

In the inaugural EBP column, Levin and Feldman (2006) cited an article by Pravikoff, Tanner, and Pierce (2005) that listed nurses' perceptions of the five top-ranked barriers to using an EBP approach to practice (after not having sufficient time) as follows: * Not valuing the contribution that research can make to practice * Lack of understanding of how to use electronic databases * Difficulty in obtaining evidence (information) * Lack of computer skills * Difficulty understanding research articles A recent editorial in Worldviews on Evidence-Based Nursing poses the following question: Should we invest time in teaching critical appraisal skills to nurses? Or, should we simply provide nurses with pre-appraised research evidence? (Bucknall & Hutchinson, 2006, p. 137). The authors of this editorial reiterate the findings above about nurses' perceptions of being overwhelmed by the tasks associated with finding, retrieving, appraising, and synthesizing evidence for best practices. Another critical question then becomes this: If we teach nurses all the skills they need to use an evidence-based approach to practice, what infrastructure do clinical agencies provide for helping to access and obtain the latest and best evidence on a clinical problem? I would like to share recent experiences I have had working with agencies to facilitate EBP integration in an attempt to flesh out the issues and challenges involved in accessing and retrieving information (i.e., the best available evidence). First, the Visiting Nurse Service of New York is in the forefront of implementing an evidence-based approach to nursing practice. Examples of these initiatives demonstrate the agency's commitment to this effort: * Partnering with Pace University to conduct a pilot study to test the effectiveness of introducing an EBP mentoring model on nurse, system, and patient outcomes * Supporting an EBP education day for nurses in the Quality Management Department * Hiring a visiting faculty member half time who is an expert (this author) in EBP in the Department of Education and Clinical Development * Developing a mentoring program for selected nurse managers to help them learn and implement EBP in their respective divisions 1 * Integration of EBP into the internship curriculum for new baccalaureate degree nursing graduates who wish to work in a home health care setting as a first nursing position As described in the literature, a major challenge the agency is now facing is difficulty in accessing the needed evidence on which to make evidence-based clinical decisions. Although the Quality Management Department has included a subscription to EBSCOhost 2 in the current year's budget, nurses are finding that access to needed information is still a problem. Access to full-text articles is limited, and no mechanisms are in place for interlibrary loan access or for health sciences librarian services to assist with searching for and negotiating retrieval of evidence. This has become particularly challenging because as nurses are adopting an EBP approach to practice, they are sharing their difficulties in accessing the needed information for the EBP projects they wish to pursue. Second, during the pilot study mentioned above (Levin, Vetter, Fineout-Overholt, Melnyk, & Barnes, 2007) funded through a grant to Pace University Lienhard School of Nursing by the Hugoton Foundation, an EBP mentor (this author) engaged nurses in learning about the EBP process and implementing it by developing an innovative practice based on the best available evidence. The project director, a Pace University professor who also served as the EBP mentor, was able to arrange for access by study participants to the university's electronic library. The library administrator agreed to provide a special identification number and password to study participants but not access to interlibrary loan. …

Sicherung der Strukturqualität in der stationären medizinischen Rehabilitation von Kindern und Jugendlichen

So far, the routine programmes of the statutory pension and health insurance institutes for quality assurance in medical rehabilitation have not included facilities for children and adolescents. Thus, a conjoint project of the statutory pension and health insurance institutes to assess and to describe the structure quality of in-patient medical rehabilitation clinics for children and adolescents was initiated. The aim of the project was a survey and an analysis of the currently existing clinic structures and the development of criteria for an evaluation of the structure quality. The Institute of Medical Psychology, University of Hamburg and the Department of Quality Management and Social Medicine, University of Freiburg were engaged to conduct the project. A questionnaire was developed in a multi-stage process with expert involvement which covers general information, characteristics of structure quality as well as structure affiliated process characteristics of clinics. The survey was planned as a cross-sectional study. Data collection was accomplished from 1.12.2004 - 15.3.2005. A total of n = 177 facility addresses were available. The return rate was 83.3 %. Eventually, n = 79 facilities were included in the analysis. In sum, the results underline the heterogeneity of services in the field of child and adolescent rehabilitation. The results allow an analysis of the current clinic structures as well as a first comparison of clinics on the basis of the assessed structure characteristics.

More Quality Bang for Your Healthcare Buck

The quality management department at North Shore-Long Island Jewish Health System has designed a collaborative process that improves patient safety, is accountable to the public, and increases efficiency on the basis of sound data management. By forging strategic alliances between the quality, finance, and materials support services departments at the health system level, a quality economic business model was developed that led to greater efficiencies in length-of-stay management, improved resource utilization in critical care, and standardization of skin care products and equipment. This article describes these quality initiatives.

A Call for Board Leadership on Quality in Hospitals

A national agenda for health care quality is unfolding but there is concern about inadequate progress on improving quality in hospitals. The 2003 Institute of Medicine report calls for transformational leadership in health care organizations to change systems and processes underlying quality. The key question is: Who will provide leadership in hospitals? A natural choice is the board of trustees on account of its legal responsibility for quality and its authority over medical staff and administration. This article describes several barriers to board leadership on quality and suggests strategies by which boards can lead the campaign for quality. Barriers include trustee ignorance, trustee insecurity, board inattention, poor board-physician communication, fragmented information on quality, traditional medical staff structure, lack of professional management of quality, and lack of investment. Strategies for hospital board leadership should include preparing to lead, self-education, visible participation in quality activities, activism, role clarification, increased informal dialogue with physicians, medical staff reform, creation of a quality management department, instituting high-quality standards, and external quality audit. Boards face a historic opportunity to transform hospital quality backed by a strong legal mandate.

Sedation: a sedation assessment and flow sheet documentation tool

The process of sedation is an integral part of pediatric practice, especially in the radiology department. Even with advances in technology, sedation is often required for optimal diagnostic quality studies. Safe sedation is a process that is both art and science. The art is the ability to use sound nursing judgment, and the science is the development of a quantifiable method to apply the art. Measurement of the effectiveness of this combination of art and science requires a sound documentation tool. Documentation of sedation is not restricted to nursing alone. It is multidisciplinary, involving information from the patient, the family, the physician directing the sedation, and hospital departments such as health information and quality management. To develop this type of documentation tool, duPont Hospital for Children formed an interdisciplinary committee in 2001. The Sedation Task Force expanded an existing form to meet the safety and quality requirements of the Joint Commission on Accreditation of Healthcare Organization's (JCAHO) standards on sedation. The resulting Sedation Assessment and Flow Sheet requires documentation of the health history, the physician's evaluation of the patient immediately before sedation, a sedation medication order, and the nurse's charting through the entire process until discharge. In addition, the form is printed with a carbon copy, which is submitted to the quality management department for analysis and quarterly reporting. This documentation tool received favorable comments during a recent JCAHO survey. It has provided a wealth of information for ongoing process improvement and a detailed history of sedation at this hospital.

Exploring the customer feedback process

In today’s increasingly competitive market, it is important both to delight and to avoid disappointing the customers. Thus, it is of value to have a systematic process for obtaining feedback from the customers, not only as a basis for corrective action relating to current products, but also as vital input to the new product development process. How can we meet our present and future customers’ expectations, if we do not have a feedback process that handles available information? This study investigates how this feedback process functions, and it seeks potential improvement. Three organizations are studied, and data are collected through interviews and personal observation. The case studies are conducted as a collaborative project with three Swedish manufacturing companies and the Department of Total Quality Management at Chalmers University of Technology.

Beth Lanham on Six Sigma in healthcare. Interview by Luc R. Pelletier.

Beth Lanham, BSN RN, is a Six Sigma Coordinator in the department of quality management, staff development and safety, at Froedtert Hospital in Milwaukee, WI. Ms. Lanham received her bachelor's degree from Otterbein College in Westerville, OH and has an extensive clinical and management background in critical care nursing. In April 2000, Ms. Lanham completed the Six Sigma Black Belt training program through the American Society for Quality. She is currently working as a Six Sigma Black Belt and is actively involved with numerous committees and projects aimed at reducing medical errors and enhancing patient safety. Ms. Lanham has presented Six Sigma initiatives at the International Quality Congress sponsored by the American Society for Quality, the University Healthcare Consortium National Conference, the International Quality and Productivity Center National Conference on Six Sigma for Healthcare Providers, and the American Hospital Association Patient Safety Leadership Fellowship Retreat. Six Sigma projects at Froedtert Hospital are aimed at reducing errors associated with patient controlled analgesia pumps, continuous intravenous infusions, narcotic sedation in postoperative patients, insulin therapy, and handling of laboratory specimens. Six Sigma has also been applied toward reducing falls on a rehabilitation unit.

Changing the system: a quality management approach to pressure injuries.

The quality management (QM) department at a large integrated healthcare system developed a methodology for preventing, predicting, and treating pressure injuries across the continuum, from acute care to long-term care to home care. The initiative, the first recipient of the Ernest A. Codman Award of the Joint Commission on Accreditation of Healthcare Organizations in the network category, resulted in decreased incidence and severity of pressure injuries, reduced length of stay, and significant cost savings to the system. The process the department used illustrates how an innovative QM program can facilitate change and institute a uniform standard of care.

Improving the care of cardiothoracic surgery patients through advanced nursing skills

All the nurses in the cardiothoracic ICU are now certified in these advanced skills. The skills are reviewed with current staff members on a yearly basis during the annual evaluation. During their orientation to the cardiothoracic ICU, new staff nurses are certified by using the original process of attending an in-service training program and demonstrating the skill 3 times. The quality management department reviews medical records daily to detect complications. In addition, we (DRZ and MB) conducted a quality assurance review in which we monitored 20 patients being extubated and having PA catheters removed by nurses. No complications were noted during either review. The institution has seen improvements in quality of care and earlier discharge from the hospital. With earlier removal of endotracheal tubes and PA catheters, patients are more comfortable and their rehabilitation can be advanced sooner. Comparison of the mean length of stay for patients undergoing coronary artery bypass graft in March 1995 with the mean length of stay for such patients in March 1998 showed a 50.6% decrease, from 14.94 days to 7.38 days. These advanced skills have provided an increased autonomy for the nurses and have benefited the patients undergoing cardiac surgery in our institution.

Prophylactic ureteral catheterization in gynecologic surgery

Objectives. To examine the frequency of ureteral catheter usage, its efficacy in preventing injury, and related complications, because the preoperative routine placement of ureteral catheters as a prophylactic measure to prevent ureteral injury is controversial. Methods. All major gynecologic operations performed between January 1992 and December 1994 were identified. All gynecologic procedures that were preceded by ureteral catheter placement were also identified. A data base maintained by the Department of Quality Management allowed identification of all urinary tract complications and ureteral injuries. Four categories of surgery were analyzed: exploratory laparotomy with catheters, exploratory laparotomy without catheters, operative laparoscopy with catheters, and operative laparoscopy without catheters. The medical records of all patients with urinary tract complications were reviewed. Results. Bilateral prophylactic ureteral catheterization was performed in 469 (15.3%) of 3071 patients. A ureteral injury occurred in 4 (0.13%) of 3071 patients. All four ureteral injuries (0.17%) occurred among 2338 patients who underwent exploratory laparotomy. None of the 733 patients who underwent operative laparoscopy suffered ureteral injury. The incidence of ureteral injury in patients who had ureteral catheters placed before exploratory laparotomy was 2 (0.62%) of 322. Two (0.10%) of 2016 patients who did not have prophylactic ureteral catheters suffered a ureteral injury. There was no statistically significant difference in the incidence of ureteral injury between patients who did and patients who did not undergo ureteral catheterization ( P = 0.094). Conclusions. The use of prophylactic ureteral catheters did not affect the rate of ureteral injury in our patients. The very low incidence of ureteral injury among our patients is attributed mainly to meticulous surgical technique.

Quality: a driving force for healthcare in the United Kingdom.

Everyone has an opinion on healthcare delivery. When the subject is a national system for healthcare delivery, opinions can become very heated--for and against! This article outlines the British National Health Service (NHS). It discusses the history and background of the NHS and how those working within its system are endeavoring to follow the path of continuous quality improvement to enable it to meet the demands of the 21st century.

Using a Performance Improvement Team to Reinvent a Mandatory Education Program

To improve employee attendance at Annual Review Day, the day when all mandatory hospitalwide education requirements are presented. The Finley Hospital (Dubuque, Iowa) initiated a performance improvement team in March 1993. Data collected previous to 1993 indicated that the compliance goal of 90% was being met only with difficulty. Data indicated three main areas where improvements could be made-communication, enforcement, and curriculum. Recommendations of task forces, with team members as leaders, were implemented. Decisions were made to change Annual Review Day to a full-day format to include all mandatory education, make outcomes competency based, and maintain cost-effectiveness. The one-year trial run began in 1994 with gradual changes in the program from a lecture and video format to an interactive game format. For example, at one point a crossword puzzle with information on infection control and bloodborne pathogens was added. The Jeopardy Game format, used to teach the principles of emergency preparedness, was added in June 1994. Full implementation of the curriculum, communication, and enforcement recommendations have resulted in 100% compliance. The performance improvement team has continued to monitor results and submit quarterly reports to the quality management department. All participants must complete and pass a competency-based test on the information covered; all 760 participants have passed. The curriculum task force continues to meet on a yearly basis to evaluate the ever-evolving format, analyze attendee evaluations, and consider annual changes to the format.

Developing a hospital report card to demonstrate value in healthcare.

The Sisters of Charity Health Care Systems, Inc., (SCHCS) developed methods to collect more than 290 data elements from its 15 hospitals to measure community benefit, illness prevention, patient satisfaction, severity of illness, appropriateness, traditional quality measures, outcome measures, maternal/child services, psychiatric services, efficiency, financial performance, and risk management. The data were compiled to produce a report card called the Hospital Quality Profile, which SCHCS hospitals now use for strategic quality planning, assessment, and monitoring. Collaboration between quality management, information systems, and financial department personnel is critical to the success of such a quality database.