Quality Improvement Framework Research Articles

Providing Evidence-Based Care, Day and Night: A Quality Improvement Initiative to Improve Intensive Care Unit Patient Sleep Quality.

Evidence-based guidelines recommend promoting sleep in the Intensive Care Unit (ICU), yet many patients experience poor sleep quality. We sought to engage allied health staff and patient families to determine barriers to sleep promotion, to measure sleep quality for ICU patients, and to evaluate the improvement in sleep quality after implementation of nursing morning report protocol and a doorway poster. The study followed an interrupted time-series framework of quality improvement. Qualitative diagnostics included focus groups and interviews with patients, families, and allied health care workers, analyzed by qualitative descriptive analysis. Quantitative diagnostics included direct observation of nurses and patients overnight. Analysis of primary outcome data used statistical process control methodology. Patients included were >18 years old, admitted overnight to a Canadian tertiary academic ICU, with a Richards Agitation Sedation Scale (RASS) ≥-2. Sleep quality was measured using the Richards Campbell Sleep Questionnaire (RCSQ). Two interventions were developed: sleep quality in morning nursing report, and a doorway poster. A total of 2332 patient nights across 7 consecutive months were included for analysis. Baseline sleep in the ICU was poor (mean RCSQ 53.7/100). Root cause-analysis identified the most prominent sleep barriers as nurse stigma associated with less active management of patients and lack of physician engagement. No significant improvement occurred over the sleep quality improvement initiative (mean RCSQ 59.5/100). Sleep quality was better among non-delirious patients compared with delirious patients (mean RCSQ 62.7 vs 53.3). The intervention of a nursing morning report protocol and sleep posters did not improve the quality of ICU patient sleep in this study. Structured interviews revealed potential sleep barriers to be addressed such as nursing stigma and inappropriate awakenings. Nursing stigma has not been previously linked to sleep quality.

An automated continuous quality improvement framework for failing student outcomes based on mathematics weaknesses

In this paper, we present a detailed action plan under continuous quality improvement (CQI) exercise of outcomes based education framework related to Mathematics concerns highlighted by the Electrical Engineering (EE) Department. Failing and low performed student learning outcomes (SOs) and course learning outcomes (COs) in range of core EE courses were observed to be linked with weak Mathematics basis of students. This feedback was achieved through an automated CQI system in EvalTools under Faculty Class Assessment Report (FCAR) tab, where each instructor is required to make reflections about failing as well as low performed SOs and COs. Feedback was reviewed comprehensively, and mathematical concepts which significantly affect the performance of students in the core EE courses were derived. Moreover, a high level of Mathematics pre-requisite covering required mathematical concepts is identified for the range of core EE courses. Consequently, well-defined tasks were assigned to continuously evaluate and monitor improvement in required Mathematics concepts to ensure SOs and COs achieved in core EE courses. Results are given to exhibit the effectiveness of continuous improvement management system (CIMS).

Re-ACT: Remote Advanced Communication Training in a Time of Crisis

BackgroundWe used a quality improvement framework to transform two-day and in-person advanced communication training (ACT) course into a remote ACT (Re-ACT) format to help clinicians improve serious illness conversation (SIC) skills. MeasuresWe assessed the reach, impact, and costs of Re-ACT and compared these measures to in-person ACT courses. InterventionsAbout 45–60 minutes of synchronous, remote sessions consisting of a didactic introduction to SIC skills, tailored to the SARS-Cov-2 (COVID-19) crisis, and a live demonstration of SICs with patient-actors. OutcomesThe transition to Re-ACT sessions resulted in reaching a greater number of clinicians in less time, although depth of content and opportunities for skill practice decreased. Although both formats were well received, Re-ACT respondents felt less prepared than ACT respondents to use SIC skills. The costs of Re-ACT were significantly less than in-person ACT courses. Conclusions/Lessons LearnedWe provided effective and well-received SIC training during a time of crisis. Future work should further define the optimal mix of in-person and remote experiences to teach SIC skills.

Improving the quality of neonatal acute kidney injury care: neonatal-specific response to the 22nd Acute Disease Quality Initiative (ADQI) conference.

With the adoption of standardized neonatal acute kidney injury (AKI) definitions over the past decade and the concomitant surge in research studies, the epidemiology of and risk factors for neonatal AKI have become much better understood. Thus, there is now a need to focus on strategies designed to improve AKI care processes with the goal of reducing the morbidity and mortality associated with neonatal AKI. The 22nd Acute Dialysis/Disease Quality Improvement (ADQI) report provides a framework for such quality improvement in adults at risk for AKI and its sequelae. While many of the concepts can be translated to neonates, there are a number of specific nuances which differ in neonatal AKI care. A group of experts in pediatric nephrology and neonatology came together to provide neonatal-specific responses to each of the 22nd ADQI consensus statements.

COVID-19 Intubation Safety: A Multidisciplinary, Rapid-Cycle Model of Improvement.

The COVID-19 pandemic has forced the health care industry to develop dynamic protocols to maximize provider safety as aerosolizing procedures, specifically intubation, increase the risk of contracting SARS-CoV-2. The authors sought to create a quality improvement framework to ensure safe practices for intubating providers, and describe a multidisciplinary model developed at an academic tertiary care facility centered on rapid-cycle improvements and real-time gap analysis to track adherence to COVID-19 intubation safety protocols. The model included an Intubation Safety Checklist, a standardized documentation template for intubations, obtaining real-time feedback, and weekly multidisciplinary team meetings to review data and implement improvements. This study captured 68 intubations in suspected COVID-19 patients and demonstrated high personal protective equipment compliance at the institution, but also identified areas for process improvement. Overall, the authors posit that an interdisciplinary workgroup and the integration of standardized processes can be used to enhance intubation safety among providers during the COVID-19 pandemic.

Ethical frameworks for quality improvement activities: an analysis of international practice.

To examine international approaches to the ethical oversight and regulation of quality improvement and clinical audit in healthcare systems. We searched grey literature including websites of national research and ethics regulatory bodies and health departments of selected countries. National guidance documents were included from six countries: Ireland, England, Australia, New Zealand, the United States of America and Canada. Data were extracted from 19 documents using an a priori framework developed from the published literature. We organized data under five themes: ethical frameworks; guidance on ethical review; consent, vulnerable groups and personal health data. Quality improvement activity tended to be outside the scope of the ethics frameworks in most countries. Only New Zealand had integrated national ethics standards for both research and quality improvement. Across countries, there is consensus that this activity should not be automatically exempted from ethical review but requires proportionate review or organizational oversight for minimal risk projects. In the majority of countries, there is a lack of guidance on participant consent, use of personal health information and inclusion of vulnerable groups in routine quality improvement. Where countries fail to provide specific ethics frameworks for quality improvement, guidance is dispersed across several organizations which may lack legal certainty. Our review demonstrates a need for appropriate oversight and responsive infrastructure for quality improvement underpinned by ethical frameworks that build equivalence with research oversight. It outlines aspects of good practice, especially The New Zealand framework that integrates research and quality improvement ethics.

Reducing Vancomycin Use in a Level IV NICU.

Vancomycin remains one of the most commonly prescribed antibiotics in NICUs despite recommendations to limit its use for known resistant infections. Baseline data revealing substantially higher vancomycin use in our NICU compared to peer institutions informed our quality improvement initiative. Our aim was to reduce the vancomycin prescribing rate in neonates hospitalized in our NICU by 50% within 1 year and sustain for 1 year. In the 60-bed level IV NICU of an academic referral center, we used a quality improvement framework to develop key drivers and interventions including (1) physician education with benchmarking antibiotic prescribing rates; (2) pharmacy-initiated 48-hour antibiotic time-outs on rounds; (3) development of clinical pathways to standardize empirical antibiotic choices for early-onset sepsis, late-onset sepsis, and necrotizing enterocolitis; coupled with (4) daily prospective audit with feedback from the antimicrobial stewardship program. We used statistical process u-charts to show vancomycin use declined from 112 to 38 days of therapy per 1000 patient-days. After education, pharmacy-initiated 48-hour time-outs, and development of clinical pathways, vancomycin use declined by 29%, and by an additional 52% after implementation of prospective audit with feedback. Vancomycin-associated acute kidney injury also declined from 1.4 to 0.1 events per 1000 patient-days. Through a sequential implementation approach of education, standardization of care with clinical pathways, pharmacist-initiated 48-hour time-outs, and prospective audit with feedback, vancomycin days of therapy declined by 66% over a 1-year period and has been sustained for 1 year.

Steps for implementing measurement-based care: Implementation planning guide development and use in quality improvement.

Although the benefits of measurement-based care (MBC) are widely noted, MBC remains underutilized in mental health services. In 2016, the Department of Veterans Affairs, Veterans Health Administration began the MBC in Mental Health Initiative to implement MBC as a standard of care across VHA mental health services. Subsequently, in January 2018 The Joint Commission (TJC) revised their behavioral health care standards to require implementation of MBC. Based on key informant interviews with early adopters across VHA, we developed an MBC Implementation Planning Guide to support implementation of MBC in diverse mental health settings. In this article, we present the MBC Implementation Planning Guide, describe how it was developed, and suggest a process for its use by implementation teams within an overall quality improvement framework to support implementation of MBC consistent with local context and TJC requirements. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Development and evaluation of a quality improvement framework for healthcare.

ObjectiveDevelop and evaluate a framework for quality improvement which will provide a common approach, terminology and greater likelihood of success in achieving demonstrable and sustained improvement.DesignDescriptive with mixed methods evaluation.SettingTertiary care academic hospital in Ottawa, Canada.ParticipantsStudents enrolled in the Quality and Patient Safety Leadership Executive Program at the local university.MethodsThe quality improvement (QI) framework was developed though comparison and coding of key strengths across four commonly applied quality improvement frameworks. Effectiveness of the framework was evaluated through a satisfaction survey of students who were taught the framework, and independent assessment of student improvement initiatives that followed the QI Framework versus initiatives from a prior year who did not.Main Outcome MeasuresAcceptability and effectiveness of the QI Framework.ResultsAll participants found the QI Framework to be useful and easy to follow. Independent evaluation of improvement initiatives following the QI Framework, as compared to those that did not, scored higher (95% CI: 3.0 ± 0.49) than the projects completed without the QI Framework (95% CI: 2.2 ± 0.30), P value < 0.01. Scores were higher for cohort 2017/18 in all criteria except scaling and spreading, in which there was no change (2015/16 95% CI: 1.2 ± 0.24, 2017/18 95% CI: 1.2 ± 0.38).ConclusionsThe method we have developed is acceptable and helpful to users, and overall application resulted in higher quality initiatives. We believe this method, which we have branded as The Ottawa Hospital Innovation Framework, can be beneficial in healthcare settings for a variety of change initiatives.

Exploring the Relationship Between Quality Rating and Improvement System Supports and Global Quality in Family Child Care

A Quality Rating and Improvement System (QRIS) is one widespread method to provide a framework for quality improvement in early care and education. However, there is little research examining the relationship between QRIS supports and quality changes in family child care programs. This study aims to examine the associations between supports offered through Delaware’s QRIS and global quality changes in family child care programs. Delaware’s QRIS supports included financial incentives and on-site technical assistance. Data were extracted from the administrative database on 139 family child care programs participating in the QRIS. Repeated measures multivariate analysis of covariance was used to examine the effects of time and Delaware’s QRIS supports. Results showed significant relationships between QRIS supports and the improvement of global quality in family child care programs as measured by the Family Child Care Environment Rating Scale-Revised. Specifically, the amount of on-site technical assistance was significantly associated with changes in the Interaction and Program Structure subscale scores. Additionally, grants received through the QRIS were significantly associated with quality improvements in the home environment. Considering that the amount of technical assistance alone was effective in improving the global quality of family child care programs, professional development strategies that aim to articulate and enhance the technical assistance that is provided to programs would be useful. Further, various types of financial incentives are encouraged to assist family child care programs in improving the structural quality of their environments.

Quality improvement and antimicrobial stewardship in general practice – the role of the municipality chief medical officer. A qualitative study

Aims This study aimed to explore the conditions for the Municipal Chief Medical Officers’ (MCMOs) involvement in quality improvement in general practice, specifically concerning antibiotic prescribing practices. Methods This qualitative study consisted of semi-structured in-depth telephone interviews and group interviews with MCMOs (n = 12). The interview guide aimed to explore the MCMOs’ views on their role and responsibilities regarding the quality of care in general practice. The data were analysed using systematic text condensation. Results Three main themes were identified: 1) the relationship between the municipality and the general practitioner (GP), with the MCMO acting as an intermediary, 2) influencing the GPs’ work and 3) antibiotic use and infection control. The MCMOs perceived themselves as liaisons between the municipalities and the GPs. They emphasized building trust, showing respect and sharing common values in their interactions with the GPs, upholding the GPs’ professional autonomy. Working for quality improvement was considered a priority; however, MCMOs expressed a need for external support to establish a permanent quality improvement framework. The informants were positive about engaging in improving antibiotic prescribing practices because this combined the municipality’s responsibilities for quality improvement and communicable disease control. Conclusions The MCMOs considered themselves as well-suited agents for quality improvement in general practice, as liaisons between the municipalities and the GPs. Quality improvement in general practice would benefit from a clearer structure in terms of the MCMOs’ roles and responsibilities. Within communicable diseases control, the MCMOs have a clear mandate, which places antimicrobial stewardship initiatives in a favourable position amongst other areas of quality improvement.

Using a Quality Improvement Framework to Target Lead Screening Rates in an Urban Academic Center

Using a Quality Improvement Framework to Target Lead Screening Rates in an Urban Academic Center

Using a Quality Improvement Framework to Target Lead Screening Rates in an Urban Academic Center

Introduction: Differences exist in federal, state, and local recommendations for lead screening and management. Handling divergent recommendations is difficult within a network that crosses state lines and serves a diverse population. This has resulted in poor support for screening within our EHR and consequently poor adherence to local lead testing recommendations. Clinical decision support was based on insurance requirements and displayed at the 9-month and 24-month visit, missing at-risk children who should have been tested according to local testing recommendation. In 2018, 88% of children (895/1009) were tested at the 9-month well child visit …

Structured opioid-free protocol following outpatient hypospadias repair - A prospective SQUIRE 2.0-compliant quality improvement initiative

Prescription opioids have been extensively to manage postoperative pain in children. A growing body of evidence from the adult literature, suggests however, that healthcare providers may be prescribing far more opioids than required, with some studies demonstrating equivalent post-operative pain and clinical outcomes with their omission. The objectives of this prospective study were to assess the current heterogeneity of practice in post-operative opioids prescription following day case hypospadias surgery, to establish a streamlined discharge protocol, and to reduce the use of post-operative opioid prescription by 30% within a 4 month period through the use of systemic forcing functions and education. This prospective study was approved by the Quality Improvement (QI) sub-committee of the hospital's Research and Ethics Board (REB) and was compliant with the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines. Recruited parents (n=84) were contacted for telephone interview following a combined intervention of education and omission of post-operative opioids from the discharge prescription. A mixture of qualitative and quantitative techniques were employed including an initial process analysis to assess current opioid use, the creation of balancing measures, and the creation of Plan-Do-Study-Act cycles. Age, procedure, post-operative outcomes and opioid prescription data were recorded over a period of 6 months in 2019. Initial measures in our process analysis demonstrated significant institutional practice variation amongst our 84 post-intervention patients. Our process and fidelity measures confirmed 100% information provision. Following the point of intervention, there was a significant and sustained drop in opioid prescription, with an absolute reduction of 35%, and a relative reduction of 56%. There was no significant difference in patient age, pain scores, or outcomes pre- and post-intervention. We have shown in this study that a sustainable decrease in post-operative opioid prescriptions following hypospadias surgery is possible. We managed to achieve a relative reduction 56% which is comparable to other specialties, however, did it within a quality improvement framework to ensure fidelity and no adverse balancing measures. We also managed to reduce the number of doses prescribed in those receiving opioids post-intervention at week 9. Our study demonstrates opioids can be safely omitted in hypospadias cohorts without any adverse clinical outcomes or balancing measures. We recommend that opioids be used extremely judiciously in this population in order to minimize exposure in children.

Implementation of Pregnancy Checklist into Clinic Workflow: AQuality Improvement Initiative.

This project aims to implement the Pregnancy Reasonably Excluded Guide in an outpatient family planning teen clinic using the EPIDEM quality improvement (QI) framework. Quality improvement. Outpatient family planning teen clinic in an urban center. Female teen clinic patients (13-19years of age). We used the EPIDEM (Explore relevant issues and contextual factors, Promote to the right people, Implement timely solutions, Document steps, Evaluate with meaningful measures, Make modifications to improve interventions further) QI framework to implement the Pregnancy Reasonably Excluded Guidein our clinic. The primary outcome was the percentage of eligible visits in which the checklist was used. The secondary outcome was the percentage of encounters in which a UPT was ordered pre- and post-implementation. A total of 383 eligible encounters were reviewed pre- and post-implementation. Before implementation, there was no use of the checklist in clinic. After implementation, 81.8% of eligible encounters used the checklist. Before implementation, 37.3 % of encounters had a UPT ordered. After implementation, 27.0% of encounters had a UPT ordered; there was a 27.6% decrease in UPTs ordered (P=.036). The pregnancy checklist can be successfully implemented using QI methodology, and the EPIDEM QI framework is a valuable clinical tool for the implementation of a context-sensitive protocol. Use of the pregnancy checklist is standard of care and has the capacity to reduce the number of unnecessary UPTs, which may provide time and cost savings in a broad range of clinical settings.

A comprehensive, integrated approach to quality improvement and capacity building in burn care and prevention in low and middle-income countries: An overview

Consistent evidence has emerged over many years that the mortality and morbidity outcomes for burn patients in low and middle-income countries (LMICs) lag behind those in more resource rich countries. Interburns is a charity that was set up with the aim of working to reduce the disparity in the number of cases of burns as well as the outcomes for patients in LMICs. This paper provides an overview of a cyclical framework for quality improvement in burn care for use in LMICs that has been developed using an iterative process over the last 10 years. Each phase of the process is outlined together with a description of the tools used to conduct a gap analysis within the service, which is then used to frame a programme of capacity enhancement. Recent externally reviewed projects have demonstrated sustained improvement with the use of this comprehensive and integrated approach over a three-year cycle. This overview paper will be supported by further publications that present these results in detail.

Digitizing Infectious Disease Clinical Guidelines for Improved Clinician Satisfaction.

The purpose of this project was to implement an improved rapid-deployment clinical decision support strategy for the detection and treatment of emerging and reemerging infectious diseases within an electronic health record informed by end-user satisfaction. After a review of the evidence and comprehensive workflow assessments, interdisciplinary focus groups were assembled to determine current infectious disease needs within the electronic health record and what guidance should be provided to clinicians to assist in making the best decisions for both patient care and population health. Education and reeducation issues were handled throughout the implementation process. Using the Plan-Do-Study-Act quality improvement framework for rapid cycle deployment, the design was implemented and monitored. To evaluate efficacy and clinician satisfaction of the implementation, presurvey and postsurvey measurements were employed. The Clinical Information System Implementation Evaluation Scale was used, along with demographic and qualitative textual questions, to evaluate clinician satisfaction. Findings indicate the implementation was successful (P < .05).

Reducing free thyroid hormone testing through multiple Plan-Do-Study-Act cycles

ObjectivesFree thyroid hormones (fT4 and fT3) are one of the most commonly ordered laboratory tests and often ordered when not clinically meaningful. Based on this, many studies have sought to identify strategies to reduce inappropriate fT4 and fT3 testing. The goal of the current study was to implement a quality improvement (QI) framework to identify an optimal approach to reducing inappropriate free thyroid hormone testing through multiple change ideas and Plan-Do-Study-Act (PDSA) cycles. The aim was to reduce fT4 and fT3 30% from baseline at a large tertiary hospital within 12 months. MethodsThe Model for Improvement Framework was used to implement a total of 3 change ideas in the first and second PDSA cycles. Change ideas included implementation and refinement of a free thyroid hormone forced function reflex system, modifications to test requisitions/order-entry interfaces, and a TSH-only option. Process and balancing measures were evaluated to fine-tune the change interventions. Data was continuously monitored pre and post interventions to assess progress, impact and potential errors. ResultsIn the first PDSA cycle, laboratory testing of fT4 was decreased by 24% and fT3 by 18%. Soliciting physician feedback and assessing balancing measures was important in refining the approach. In the second PDSA cycle, fT4 was decreased by an additional 16% and fT3 by 29%. An audit of the process showed that phone calls to the laboratory to add-on free thyroid hormones did not increase after the second PDSA, averaging 2 calls per month. ConclusionsTo achieve optimal reductions in free thyroid hormone testing, multiple PDSA cycles were required alongside assessing process and balancing measures. Overall, fT4 and fT3 testing was decreased by 39% and 47%, respectively.

MON-118 Reducing Unnecessary Repeat HbA1c Testing in a Tertiary Academic Hospital

BackgroundGlycated hemoglobin (HbA1c) is a surrogate marker of glycemia over the preceding three months, where the last 30 days contributes to 50% of the value (1). Therefore guidelines often recommend repeating HbA1c only after 3 months in most situations (2), but repeat testing of HbA1c is often conducted earlier when not warranted (3). We aimed to conduct a Quality Improvement (QI) initiative to reduce unnecessary repeat testing of HbA1c at a large tertiary care academic hospital in Toronto, Ontario by 50% by May 2020.Methods:The Model for Improvement Quality Improvement (QI) framework was used in the design of the QI project to reduce repeat HbA1c. Problem characterization was conducted to understand root causes and iterative Plan-Do-Study-Act cycles were used to develop a change intervention. Unnecessary HbA1c tests were the primary outcome and defined as repeat HbA1c testing within 60 days; the top three specialities that ordered unnecessary HbA1c tests were targeted for education prior to implementation of the change intervention.Results:Baseline data on all HbA1c tests in 2018 revealed repeat testing in approximately 10% of 15,290 HbA1c tests, with estimated potential savings of more than $11,000 based on the provincial reimbursement rate. The top 3 ordering specialities targeted for education included Nephrology (n=410 repeat HbA1c tests), Cardiology (n=246 repeat HbA1c tests), and Endocrinology (n=136 repeat HbA1C tests). Root cause analysis revealed that providers often ordered repeat HbA1c tests due to being unaware of prior results and a knowledge gap of testing recommendations. A laboratory forced function will be implemented on December 1, 2019 to cancel any repeat HbA1c tests within 60 days and calls to the lab to add HbA1c testing will be tracked.Conclusions:Repeat HbA1c testing is frequent in hospital settings and can be an important target for QI efforts. A forced function to cancel processing of repeat HbA1c may be an appropriate QI intervention to reduce repeat testing to promote high-value care. Ongoing data analysis will be conducted to assess the impact of this intervention.References(1) Goldstein DE, Little RR, Lorenz RA, Malone JI, Nathan D, Peterson CM, Sacks DB. Tests of Glycemia in Diabetes. Diabetes Care 2004;27(7): 1761-1773.(2) Berard LD, Siemens R, Woo V. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Monitoring Glycemic Control. Can J Diabetes 2018;42(Suppl 1):S47-S53.(3) Chami N, Simons JE, Sweetman A, Don-Wauchope AC. Rates of inappropriate laboratory test utilization in Ontario. Clinical Biochemistry 2017;50: 822-827.

How Do We Align Health Services Research and Quality Improvement?

Quality improvement (QI) initiatives and health services research (HSR) are commonly used to target health care quality. These disciplines are increasingly important because of the movement toward value-based health care as alternative payment and care delivery models drive institutions and investigators to focus on reducing unnecessary health care use and improving care coordination. QI efforts frequently target medical error and/or efficiency of care through the Plan-Do-Study-Act methodology. Within the QI framework, strategies for data display (e.g., Pareto charts, run charts, histograms, scatter plots) are leveraged to identify opportunities for intervention and improvement. HSR is a multidisciplinary field of study that seeks to identify the most effective way to organize, deliver, and finance health care to maximize the quality and value of care at both the individual and population levels. HSR uses a diverse set of quantitative and qualitative methodologies, such as case-control studies, cohort studies, randomized control trials, and semistructured interview/focus group evaluations. This manuscript provides examples of methodologic approaches for QI and HSR, discusses potential challenges associated with concurrent quality efforts, and identifies strategies to successfully leverage the strengths of each discipline in care delivery.