Drive Quality Improvement Research Articles

Surgical Rescue in a High-volume Urban Emergency General Surgery Service at a Middle-income Country.

Introduction:The capacity for prompt “rescue” from death in patients with complications has become an important marker of the quality of care since mortality and morbidity have been identified as incongruous indicators. This study aims to describe the incidence of “surgical rescue” failure and the outcomes of emergency general surgery (EGS) patients at a large academic medical center.Materials and methods:In our high-volume surgical hospital, an electronic EGS registry was developed to automatically capture in-hospital information and outcomes from the Electronic Medical Record (EMR). Surgical complications were included in an online application and automatically captured in the electronic EGS registry, and prospectively screened from June to July 2017 for acute EGS surgical patients from operative procedures.Results:A total of 501 patients (average age: 53.9 ± 20.9, 56.5% female) underwent 882 EGS procedures. Thirteen patients (2.6%) of the 501 patients required “surgical rescue”, mainly for uncontrolled sepsis (43%) and anastomotic leakage (30%). The surgical rescue failure rate (inability to prevent death after a surgical complication) was 15.4%. Patients requiring critical care (OR = 3.3, IC 95%: 1.04, 10.5), hospital admission (p = 0.038), and hospital LOS (days) (p = 0.004) were significantly higher for the surgical rescue patients than for those without complications.Conclusion:Surgical failure to rescue rate was similar among high-volume EGS services, as has recently been described in the United States. The latest development and implementation of an electronic automatic captured EGS registry database in our academic medical center will serve to build best practices for “surgical rescue” and drive quality improvement programs.

Improving data quality for human-as-a-security-sensor. A process driven quality improvement approach for user-provided incident information

Purpose In the past, people were usually seen as the weakest link in the IT security chain. However, this view has changed in recent years and people are no longer seen only as a problem, but also as part of the solution. In research, this change is reflected in the fact that people are enabled to report security incidents that they have detected. During this reporting process, however, it is important to ensure that the reports are submitted with the highest possible data quality. This paper aims to provide a process-driven quality improvement approach for human-as-a-security-sensor information. Design/methodology/approach This work builds upon existing approaches for structured reporting of security incidents. In the first step, relevant data quality dimensions and influencing factors are defined. Based on this, an approach for quality improvement is proposed. To demonstrate the feasibility of the approach, it is prototypically implemented and evaluated using an exemplary use case. Findings In this paper, a process-driven approach is proposed, which allows improving the data quality by analyzing the similarity of incidents. It is shown that this approach is feasible and leads to better data quality with real-world data. Originality/value The originality of the approach lies in the fact that data quality is already improved during the reporting of an incident. In addition, approaches from other areas, such as recommender systems, are applied innovatively to the area of the human-as-a-security-sensor.

Driving quality improvement with a massive open online course (MOOC)

BackgroundQuality improvement (QI) is a priority for national regulatory bodies in health and care in the UK. However, many health and care staff do not know where to go for...

Barriers of Intraprenurship Practice at South African Public Hospitals: Perspectives of Unit Nurse Managers

The paper highlights the barriers of intrapreneurship practice experienced by unit nurse managers working within the embattled public hospitals. The qualitative study was, descriptive, explorative and contextual in nature. The focus groups’discussions shed light on the plight of front runners constantly experiencing numerous intrapreneurial barriers frustrating ideation into implementable transformative programs. The barriers identified in this study include; lack of resources, security issues affecting freedom of staff and patients, poor staff ratios impacting on the rights of staff and patients, poor communication and unfair incentivised performance management system. The minimal conceptualization of intrapreneurship being quite foreign to nursing revealed in the findings is a wakeup call for senior teams pressured to improve performance. A number of public hospitals reforms consider the salient contribution of human capital in health care being key in driving quality improvement initiatives. Capacity development measures in education and clinical practice is a sensible recommendation through empowering nurses on business inclined management strategies like intrapreneurship practice improving the health care outcomes.

Aged Care Residents' Perspectives on Quality of Care in Care Homes: A Systematic Review of Qualitative Evidence.

There is increasing interest in harnessing aged care residents' perspectives to drive quality improvement in aged care homes. We conducted a systematic review of qualitative evidence including literature examining residents' descriptions of "quality of care" in aged care homes, using database searches and screening records according to eligibility criteria. Three independent reviewers conducted quality assessment of forty-six eligible articles and performed thematic synthesis of articles' findings. We distinguish nine key themes describing factors influencing quality care: staffing levels, staff attitude, continuity, routine, environment, decision-making and choice, dignity of risk, activities, and culture and spirituality. While many themes were consistent across studies, residents' prioritization of them varied. Aged care home residents have differing conceptions of quality care as well as heterogeneous and dynamic needs and preferences. Care providers are best able to facilitate quality care when intentional efforts are made to recognize this and tailor delivery of services the individual residents.

Implementing a hip fracture registry and financial incentive program to enhance best practice in hip fracture care in Western Australia.

Hip fracture is a common injury in older adults that causes significant morbidity and mortality. Older adults who sustain a hip fracture are at a higher risk of institutionalisation, reduced mobility and subsequent falls and, consequently, have increased rates of morbidity and mortality. Quality improvement strategies that address gaps in hip fracture care are needed to ensure best practice and improve health outcomes for older adults.

Provider Specialty and Receipt of Metabolic Monitoring for Children Taking Antipsychotics.

Metabolic monitoring is important for children taking antipsychotic medication, given the risk for increased BMI, impaired glucose metabolism, and hyperlipidemia. The purpose was to examine the influence of provider specialty on the receipt of metabolic monitoring. Specifically, differences in the receipt of recommended care when a child receives outpatient care from a primary care provider (PCP), a mental health provider with prescribing privileges, or both was examined. Medicaid enrollment and health care and pharmacy claims data from 2 states were used in the analyses. Providers were assigned to specialties by using a crosswalk of the National Provider Identifier numbers to specialty type. A total of 41 078 children were included. For both states, 61% of children saw ≥1 provider type and had adjusted odds ratios for receiving metabolic monitoring that were significantly higher than those of children seeing PCPs only. For example, children seeing a PCP and a mental health provider with prescribing privileges during the year had adjusted odds of receiving metabolic monitoring that were 42% higher than those seeing a PCP alone (P < .001). Shared care arrangements significantly increased the chances that metabolic monitoring would be done. For states, health plans, and clinicians to develop meaningful quality improvement strategies, identifying the multiple providers caring for the children and potentially responsible for ordering tests consistent with evidence-based care is essential. Provider attribution in the context of shared care arrangements plays a critical role in driving quality improvement efforts.

Accreditation Program for Excellence (APEx): A Catalyst for Quality Improvement

PurposeIn 2014 the American Society for Radiation Oncology’s Accreditation Program for Excellence (APEx) was created in response to the Target Safely campaign. APEx is a powerful tool to measure and drive quality improvement in radiation oncology practices. Methods and MaterialsA task group from the American Society for Radiation Oncology’s Practice Accreditation Committee was formed to provide an overview of the APEx accreditation program including analysis from specific program data. ResultsThrough initiatives encouraged by the APEx program, participants are able to evaluate teamwork and effectiveness, implement documented procedures aimed at improving quality and safety, and establish quality management at the practice. The program's Self-Assessment measures performance with program requirements and indicates where compliance lacks standardization. Methods to address these deficiencies form part of on-going quality improvement. These quality outcomes promote the delivery of safe, high-quality care. ConclusionThe accreditation process through APEx is a commitment to an ongoing safety culture. Any worthwhile accreditation program should provide a meaningful assessment of practice operations, supply the tools to identify deficiencies and provide the opportunity to showcase growth and development. A commitment to completing APEx is a commitment to excellence for patients and all those who care for them.

Informatics driven quality improvement in the modern histology lab

Laboratory Information Systems (LIS) and data visualization techniques have untapped potential in anatomic pathology laboratories. Pre-built functionalities of LIS do not address all the needs of a modern histology laboratory. For instance, “Go live” is not the end of LIS customization, but just the beginning. After closely evaluating various histology lab workflows, we implemented several custom data analytics dashboards and additional LIS functionalities to monitor and address weaknesses. Herein, we present our experience in LIS and data-tracking solutions that improved trainee education, slide logistics, staffing/instrumentation lobbying, and task tracking. The latter was addressed through the creation of a novel “status board” akin to those seen in inpatient wards. These use-cases can benefit other histology laboratories.

Measuring health care quality: Implications, threats, and opportunities for clinical pharmacists

AbstractThe Patient Protection and Affordable Care Act of 2010 has helped usher in an era of focus on health care quality and quality improvement. Since then, a variety of programs has driven quality improvement throughout the health care system using a combination of incentives and penalties. Many studies have demonstrated the value of integrating clinical pharmacist services into interdisciplinary models of care for the purpose of moving the needle on performance measures. The implementation of quality‐linked reimbursement programs has the greatest potential to meaningfully improve quality of care and reduce costs. However, the benefits of quality measures are dependent on their implementation into measurement systems and their application into clinical practice. Common threats to quality measurement in pharmacy practice may arise due to misapplication of health plan‐related measures to evaluate pharmacy services. Additionally, the core concepts related to novel reimbursement models have not adequately percolated into the formal education of practicing pharmacists. Therefore, the goal of this article is to help educate and raise awareness about the current quality landscape and present opportunities and directions for pharmacists to demonstrate their value in interdisciplinary health care teams. This article is broadly divided into four sections—first, we provide an introduction to quality measurement and its application to clinical pharmacists. Second, we elaborate on the development and endorsement of quality measures and measurement systems. Third, we present clinical scenarios of patient care—set in inpatient, ambulatory care, and community practice settings—that engage pharmacists in the context of quality measurement and evaluate the implications, threats, and opportunities for clinical pharmacists in each of these scenarios. Finally, we present recommendations for future advocacy, measurement, and leadership for pharmacist involvement in the quality landscape.

Leveraging a Digital Care Platform to Drive Quality Improvement in Postoperative Opioid Medication Use

Leveraging a Digital Care Platform to Drive Quality Improvement in Postoperative Opioid Medication Use

Using patient feedback to drive quality improvement in hospitals: a qualitative study

ObjectivesAlthough different forms of patient feedback are available, their use in hospital management is still limited. The objective of this study is to explore how patient feedback is currently used...

Implementation of a High-Flow Nasal Cannula Management Protocol in the Pediatric ICU.

High-flow nasal cannula (HFNC) therapy is a respiratory modality that has been adopted to support pediatric patients with bronchiolitis. There is no standardized protocol for initiation, escalation, or weaning of HFNC in the pediatric ICU. The aim of this respiratory therapist (RT)-driven quality improvement management protocol was to decrease duration of HFNC. An RT-driven HFNC management protocol based on an objective respiratory score was implemented in 2017 at a quaternary care children's hospital. Subjects included children less than 2 y old admitted to the pediatric ICU with bronchiolitis. All subjects needing HFNC were scored and placed within the protocol as appropriate for age, then weaned or escalated per the scoring tool. Comparison to a pre-intervention control group was performed. Average HFNC duration per subject was used as the primary outcome measure. Protocol compliance was used as a process measure. Noninvasive ventilation use, intubation rate, and 30-d pediatric ICU readmission rate were used as balancing measures. RT satisfaction with HFNC management before and after protocol implementation were measured. Protocol compliance was sustainable and above the goal of 80% after 4months of protocol implementation. HFNC duration decreased from 2.5 d to 2 days for each subject during planning and then to 1.8 d after protocol implementation. Length of stay (LOS) in the pediatric ICU and hospital LOS decreased from 2.6 d to 2.1 d and from 5.7 d to 4.7 dafter protocol implementation, respectively. The use of noninvasive ventilation and the rate of intubation did not change significantly. RTs reported increased involvement in HFNC management decisions and appropriateness on how quickly the team weaned HFNC. An RT-driven HFNC management protocol was safely implemented in a pediatric ICU and decreased HFNC duration, pediatric ICU LOS, and hospital LOS. It allows the RT to work independently to the highest extent of their scope of practice, leading to improvement in RT job satisfaction.

Measurement-based Data to Monitor Quality: Why Specification at the Population Level Matter?

Measurement-based care is conceptualized as a driver for quality improvement. The triple aim in the National Quality Strategy purposively muddles the population levels to provide a health policy goal that is encompassing, transactional, and will stimulate change. Specification of the population level has implications for the purpose, proposed target mechanisms that drive quality improvement, methodologic challenges, and implications for program evaluation and data interpretation. To demonstrate, population levels are conceptualized at the individual (tier 1), clinical aggregate (tier 2), and national level (tier 3).

Comparing short-term AIS post-operative complications between ACS-NSQIP and a surgeon study group

Prospective cohort review. To compare two AIS databases to determine if a performance improvement-based surgeon group has different outcomes compared to a national database. The American College of Surgeon's National Quality Improvement Program (ACS-NSQIP) and a surgeon study group (SG) collect prospective data on AIS surgery outcomes. NSQIP offers open enrollment to all institutions, and SG membership is limited to 15 high-volume institutions, with a major initiative to improve surgeon performance. While both provide important outcome benchmarks, they may reflect outcomes that are not relatable nationwide. The ASC-NSQIP Pediatric Spine Fusion and SG database were queried for AIS 30- and 90-day complication data for 2014 and 2015. Prospective enrollment and a dedicated site coordinator with rigorous data quality assurance protocols existed for both registries. Outcomes were compared between groups with respect to superficial and deep surgical site infections (SSI), neurologic injury, readmission, and reoperation. There were a total of 2927 AIS patients included in the ASC-NSQIP data and 721 in the SG database. Total complication rate was 9.4% NSQIP and 3.6% SG. At 90days, there were fewer surgical site infections reported by SG than ASC-NSQIP (0.6% vs. 1.6%, p = 0.03). Similarly, there were less spinal cord injuries (0.8% vs 1.5%, p = 0.006), 30-day readmissions (0.8% vs. 2.6%, p = 0.002), and 30-day reoperations (0.6% vs. 1.7%, p = 0.02) in the SG cohort. Comparison of these two data sets suggests a range of complications and readmission rates, with the SG demonstrating lower values. These results are likely multi-factorial with the performance improvement initiative of the SG playing a role. Understanding the rate and ultimate risk factors for readmission and complications from big data sources has the potential to further drive quality improvement. III.

Abstract 26: A novel electronic platform to improve clinical trial workflow and screening

Abstract Background: Early-phase clinical trials are increasingly complex, with “seamless” phase I/II trial designs that include multiple parallel disease and/or biomarker-selected expansion cohorts. Challenges for participating sites in phase 1 (P1) trials include rapid identification of patients for available trial slots, high screen failure (SF) rates, and workload distribution among nurses and data coordinators. The Princess Margaret (PM) Cancer Centre Solid Tumor P1 program is the largest early-phase clinical trial program in Canada. There are currently 53 actively recruiting clinical trials, and approximately 250-300 patients are enrolled annually. To improve operational efficiency at the point of care, we designed a novel electronic platform, termed Phase One Spot Tracker (POST). Methods: An electronic, password-restricted, web-based tracker and smartphone-enabled app was created using PHP Laravel, JavaScript (iOS), and Java (Android). The intention was to replace the two previously used Excel spreadsheets, where one listed the trial information and the other included available slot allocations by trial. These spreadsheets were cumbersome to use in clinic, without the ability to search or filter. POST enabled all users to access the data from any computer or phone, increased the ease of updating information in real time, and functioned as a search engine to locate available spots more quickly. It contains specific information including brief trial description, key eligibility criteria, biopsy requirements, status of trial slots (e.g., screening, available, pending, etc.). The data security of POST is ensured by Amazon Web Services. Results: Prior to launching POST, three time-measured simulations showed that it reduced the coordinators’ workload to update trial information by 30 minutes. Currently POST is used by 65 users, including 7 physicians, 14 nurses, and 29 coordinators at the PM Cancer Centre. POST is used by investigators during a weekly P1 new patient consultation clinic to identify trial candidates as well as in weekly P1 team meetings to review all patients enrolled and approached for clinical trials. We are enhancing the POST platform to enable tracking of SF (patients who undergo study-specific screening procedures but are not enrolled in a clinical trial), timeline for replacing patients who screen fail, and reasons for SF. Conclusions: POST is an electronic, smart phone-enabled platform that can be implemented at the point of care for early-phase clinical trials. POST can also provide real-time tracking data about operational metrics (startup time, screening time, enrollment data, nursing and data coordinator workload, and screen failures) that can be used to drive quality improvement. POST can be extended to other disease site groups as well as to other institutions. This will eventually lead to an increase in work efficiency and provide a better quality of care for cancer patients. Citation Format: Ramy R. Saleh, Olivia Chan, Silvi Kuld, Patrick Marban, Anna Spreafico, Aaron Hansen, Albiruni Razak, Lillian L. Siu, Philippe L. Bedard. A novel electronic platform to improve clinical trial workflow and screening [abstract]. In: Proceedings of the AACR Special Conference on Advancing Precision Medicine Drug Development: Incorporation of Real-World Data and Other Novel Strategies; Jan 9-12, 2020; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(12_Suppl_1):Abstract nr 26.

Ethical considerations for paediatrics during the COVID-19 pandemic: A discussion paper from the Australian Paediatric Clinical Ethics Collaboration.

Children have not been severely affected by SARS-CoV-2-related illness but are vulnerable to the economic and social deprivation arising from the pandemic. This document describes unique risks and burdens for children and their care givers during the COVID-19 pandemic.

Driving quality improvement: How clinical decision support can facilitate compliance with evidence-based pathways.

2045 Background: Cancer care is changing rapidly with more detailed understanding of disease and more numerous therapeutic choices. As treatment choice is more complex, mechanisms to improve compliance with evidence based treatment can improve the quality of cancer care. Methods: A retrospective cohort study was conducted from January 2014-May 2016 evaluating the impact of a clinical decision support system (CDSS) on compliance with evidence based pathways (EBP) across 9 statewide community based oncology practices. These EBP are developed with physician input on efficacy toxicity and value and incorporated in to a CDSS that is used within the Electronic Health Record (EHR) at point of care to alter the choice architecture a clinician sees when prescribing therapy. A multi-level logistic regression model was used to adjust for group effects on physician or practice behavior. SAS 9.4 software was used and GLIMMIX was applied. Individual physician benchmark compliance was evaluated using McNemar's test. Results: Regimen compliance with EBP was measured pre- and post- implementation of the CDSS tool across a large network encompassing 9 statewide practices and 633 physicians who prescribed over 30,000 individual patient treatment regimens over a 6 month period. The CDSS that is incorporated within the EHR significantly improved compliance with EBP across the entire cohort of practices, and in individual practices (see Table). Individual oncologists reached a target of 75% compliance more often (58% vs 72%) after implementation of the tool (p &lt; 0.001). Conclusions: CDSS is a tool that improves compliance with EBP that is effective at improving targets of compliance broadly, at the practice, and at the individual clinician level. Clinical informatics solutions that influence physician behavior can be inclusive of physicians in design, iterative in process, and nudge as opposed to force clinician behavior to drive quality improvement. These clinical informatics solutions grow in importance as the complexity of cancer care continues to increase and we seek to improve upon the quality and value of care delivery. [Table: see text]

Ventilator-associated Events in Children: Controversies and Research Needs.

Ventilator-associated Events in Children: Controversies and Research Needs.

British Society of Gastroenterology (BSG)-led multisociety consensus care bundle for the early clinical management of acute upper gastrointestinal bleeding

Medical care bundles improve standards of care and patient outcomes. Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency which has been consistently associated with suboptimal care. We aimed...