Quality Improvement Framework Research Articles

Service Utilisation of an Innovative Mental Health Counselling Clinic

Abstract Responding to the increasing challenges to mental health equity, Talk It Out Counseling Clinic (the Clinic), an innovative, public-facing counselling service, was established at the University of Toronto during the pandemic. Operating on the principles of anti-oppression and trauma-informed care, the Clinic trains Master of Social Work students to deliver mental health counselling to populations encountering multiple barriers to mental health equity through phone or video. Guided by a quality improvement framework, this study used chart reviews to examine the demographic characteristics, initial mental health status and service utilisation of clients (N = 116) who completed services at the Clinic during its inaugural year. Three-quarters of the clients identified as Black or other racialised individuals, and over 70 per cent rated their general mental health as poor or fair. Nearly 80 per cent of clients referred to the Clinic proceeded to an intake, amongst whom 69.6 per cent successfully completed the services. Warm handoff was associated with service engagement, whilist men and older clients were more likely to terminate the services prematurely. The study underscores the mental health needs of communities confronting multiple challenges and illuminates the processes conducive to client engagement and service delivery within an innovative, school-run mental health clinic.

An ORL-DLNN and IFIM-MST Framework for Data Quality Improvement in Modern Master Data Management

The process of generating and maintaining a master record for each person in a business is called Master Data Management (MDM). But, during Modern Master Data Management (MMDM), the prevailing methodologies did not focus on data loss. Hence, an Optimal with Recover Layer-based Deep Learning Neural Network (ORL-DLNN) and Indexed Fisher Information Matrix-based Minimum Spanning Tree-based Modern Master Data Management (IFIM-MST-based MMDM) is proposed in this paper. The source data is taken and pre-processed during training. Then, the products are clustered, and the attributes are extracted. Thereafter, by utilizing Dynamic Function-based Gold Rush Optimization (DF-GRO), the optimal attributes are selected. Afterward, for performing format classification with error detection, ORL-DLNN is introduced. Then, by utilizing the Reconciliation Rule (RR), the detected errors are corrected. After that, by utilizing the IFIM-MST, the text records are stored in the primary drive and the video and images are stored in the external drive. The details are entered by the information stewards into the classifier during testing. The data will be corrected if correction is present. Then, for verifying whether the data must be stored or not, some conditions are checked. Hence, the outcomes illustrated that the proposed system obtained a high accuracy of 98.3%, thus outperforming the existing techniques

The AACN essentials: An intentional framework for successful implementation

Nursing education is shifting toward competency-based education (CBE) in line with the American Association of Colleges of Nursing's (AACN) 2021 Essentials. This pedagogical shift from knowledge-based leaner outcomes to competency-based learner and program outcomes affects how faculty teach, how students learn, and how programs allocate resources to support this change. The initial move toward CBE necessitates scrutiny of current curricula and alignment of curriculum, teaching strategies, and assessment tactics framed within the ten domains of the Essentials.Drawing on the Donabedian quality improvement framework, one school of nursing's curricular revisions project team discusses their strategies and challenges in implementing the AACN Essentials, illustrating the structural, procedural, and initial outcomes of adopting the Essentials across programs and specialties.Key to this approach is engaging all relevant stakeholders and mapping current curricula to the Essentials' many competencies and subcompetencies. This work informs curricular revisions and fosters faculty engagement and creativity. Lessons learned highlight a critical need for ongoing faculty development and use of learner-centric pedagogies to achieve students' competency development and practice readiness.This article offers insights and guidance for nursing programs embracing CBE and aligning with AACN Essentials.

Growing together: Optimization of care through quality improvement for the mother/infant dyad affected by perinatal opioid use

The care of the dyad affected by opioid use disorder (OUD) requires a multi-disciplinary approach that can be challenging for institutions to develop and maintain. However, over the years, many institutions have developed quality improvement (QI) initiatives aimed at improving outcomes for the mother, baby, and family. Over time, QI efforts targeting OUD in the perinatal period have evolved from focusing separately on the mother and baby to efforts addressing care of the dyad and family during pregnancy, delivery, and postpartum. Here, we review recent and impactful QI initiatives that serve as examples of work improving outcomes for this population. Further, we advocate that this work be done through a racial equity lens, given ongoing inequities in the care of particularly non-white populations with substance use disorders. Through QI frameworks, even small interventions can result in meaningful changes to the care of babies and families and improved outcomes.

Integrated quality 4.0 framework for quality improvement based on Six Sigma and machine learning techniques towards zero-defect manufacturing

PurposeThis research paper aims to analyze the scientific and grey literature on Quality 4.0 and zero-defect manufacturing (ZDM) frameworks to develop an integrated quality 4.0 framework (IQ4.0F) for quality improvement (QI) based on Six Sigma and machine learning (ML) techniques towards ZDM. The IQ4.0F aims to contribute to the advancement of defect prediction approaches in diverse manufacturing processes. Furthermore, the work enables a comprehensive analysis of process variables influencing product quality with emphasis on the use of supervised and unsupervised ML techniques in Six Sigma’s DMAIC (Define, Measure, Analyze, Improve and Control) cycle stage of “Analyze.”Design/methodology/approachThe research methodology employed a systematic literature review (SLR) based on PRISMA guidelines to develop the integrated framework, followed by a real industrial case study set in the automotive industry to fulfill the objectives of verifying and validating the proposed IQ4.0F with primary data.FindingsThis research work demonstrates the value of a “stepwise framework” to facilitate a shift from conventional quality management systems (QMSs) to QMSs 4.0. It uses the IDEF0 modeling methodology and Six Sigma’s DMAIC cycle to structure the steps to be followed to adopt the Quality 4.0 paradigm for QI. It also proves the worth of integrating Six Sigma and ML techniques into the “Analyze” stage of the DMAIC cycle for improving defect prediction in manufacturing processes and supporting problem-solving activities for quality managers.Originality/valueThis research paper introduces a first-of-its-kind Quality 4.0 framework – the IQ4.0F. Each step of the IQ4.0F was verified and validated in an original industrial case study set in the automotive industry. It is the first Quality 4.0 framework, according to the SLR conducted, to utilize the principal component analysis technique as a substitute for “Screening Design” in the Design of Experiments phase and K-means clustering technique for multivariable analysis, identifying process parameters that significantly impact product quality. The proposed IQ4.0F not only empowers decision-makers with the knowledge to launch a Quality 4.0 initiative but also provides quality managers with a systematic problem-solving methodology for quality improvement.

Quality measures in pre-liver transplant care by the Practice Metrics Committee of the American Association for the Study of Liver Diseases.

The LT evaluation and waitlisting process is subject to variations in care that can impede quality. The American Association for the Study of Liver Diseases (AASLD) Practice Metrics Committee (PMC) developed quality measures and patient-reported experience measures (PREMs) along the continuum of pre-LT care to reduce care variation and guide patient-centered care. Following a systematic literature review, candidate pre-LT measures were grouped into four phases of care: referral, evaluation and waitlisting, waitlist management, and organ acceptance. A modified Delphi panel with content expertise in hepatology, transplant surgery, psychiatry, transplant infectious disease, palliative care and social work selected the final set. Candidate PREMs spanned domains of cognitive health, emotional health, social well-being, and understanding the LT process. Of the 71 candidate measures, 41 were selected: 9 for referral; 20 for evaluation and waitlisting; 7 for waitlist management; and 5 for organ acceptance. A total of 14 were related to structure, 17 were process measures and 10 were outcome measures that focused on elements not typically measured in routine care. Among the PREMs, LT candidates rated items from understanding the LT process domain as the most important. The proposed pre-LT measures provide a framework for quality improvement and care standardization among LT candidates. Select measures apply to various stakeholders such as referring practitioners in the community and LT centers. Clinically meaningful measures that are distinct from those used for regulatory transplant reporting may facilitate local QI initiatives to improve access and quality of care.

The Life Cycle of a Code White: A Framework for Managing Workplace Violence

A global challenge affecting health care organizations in the Covid-19 pandemic recovery era has been an increase in the incident frequency as well as qualitative severity and complexity of workplace violence (WPV) incidents. In Ontario, Canada, WPV in health care settings is often managed using an emergency response procedure known as a Code White (CW). The Toronto-based University Health Network (UHN) — a research and teaching hospital network with four centers of care and about 18,000 employees (including about 1,200 physicians and 3,900 registered nurses), a learning institute serving about 17,500 learners, and a research team with about 1,150 principal investigators — has engaged in a comprehensive quality improvement (QI) framework with the view to fully understand the complexity of CWs and effectively implement and evaluate complex interventions required to address the multidimensional problem of WPV. As part of this effort, UHN has developed the Life Cycle of a Code White (LCCW) by leveraging principles of System Engineering Initiative for Patient Safety 101, including the application of a journey map to outline the steps and involvement of specific functional units in CW incidents. This task necessitated extensive engagement with diverse stakeholders across the organization. The authors provide an example of how the LCCW initiative can be applied to enable the organization to operationalize the complexity of CW QI, catalyzing the formation of a formal CW governance structure, 12 distinct QI initiatives, and 17 quality indicators to inform data-driven change management.

Research on Aerospace Software Quality Improvement Based on Software Test Data Analysis

This paper addresses the issue of underutilized software test data in current aerospace software quality management. Through analyzing the current third-party software evaluation process, the paper proposes to optimize software evaluation process and management to enhance software development quality and software test quality. The paper proposes an aerospace software quality improvement framework based on software test data analysis, which provides a reference scheme for aerospace software quality management. Overall, the paper emphasizes the importance of software test data analysis in improving aerospace software quality and provides a comprehensive solution for addressing problems identified in aerospace software quality management.

"The infinity loop of healthcare innovation: Development of an integrated rehabilitation pathway for spinal surgery through design thinking"

Introduction: One of the biggest fears of most clinical researchers is the translational “valley of death”, where scientific evidence (what is known) is lost in translation towards clinical practice (what is done). Bridging this know-do valley is challenging, and often targeted through developing a clinical “pathway”. Traditional frameworks for pathway development are known to be researcher-centered and linear. To overcome these shortcomings, we propose design thinking as a new framework for developing more user-centered clinical pathways. Whereas today, design thinking is increasingly embraced by healthcare for designing ‘things’ such as medical software or devices, we aim to also pave the way for design thinking in ‘pathway’ design. In particular, we adopted design thinking in developing a rehabilitation pathway for patients undergoing spinal surgery to improve the suboptimal outcomes such as persistent pain, disability and sick leave. 
 Methods: From 2017 to 2022, we adopted the infinity loop of design thinking (revisualization of Stanford’s d.school framework) to develop an evidence-based, integrated rehabilitation pathway for patients following spinal surgery (more specifically lumbar fusion), and reported this in line with the ‘Guideline for reporting research involving design’. The infinity loop includes five phases, which are non-linear (back-and-forth is possible), continuous (‘trying to solve a problem can help you better understand it’), and user-centered: 
 i) Empathize: to understand (explicit and latent) user needs, we observed the current practice in a prospective cohort of 36 patients and engaged through semi-structured interviews with five patients and 31 healthcare providers. 
 ii) Define: we formulated two problem statements, one for each user group (patients and healthcare providers), that together underline the pathway characteristics needed: easy-to-use, evidence-based, interdisciplinary and transmural.
 iii) Ideate: we summarized the current evidence in a meta-analysis of 18 randomized-controlled trials, and gained 122 consensus statements from a multidisciplinary 31-member expert panel via a modified Delphi study, which was validated by nine patients. 
 iv) Prototype: a time-task prototype of the rehabilitation pathway was created in line with the principles of process mapping. This prototype underwent iterative cycles of mono- and multidisciplinary feedback and improvement and patient involvement on clarity of the final prototype.
 v) Test: testing is currently ongoing in a tertiary hospital. The effectiveness (in terms of disability and return to work) and implementability of this rehabilitation pathway will be evaluated. Feedback loops with qualitative user feedback through interviews with patients and focus groups with healthcare providers will continuously improve the design.
 Results: An integrated rehabilitation pathway for spinal surgery was designed, and is ready for implementation. This rehabilitation pathway is evidence-based, addresses the needs of patients and providers, and involves innovative components such as prehabilitation, early mobilization, uniform communication through leaflets, videos and website, and limited postoperative restrictions. This use case provides a practical guide for adopting design thinking in the context of clinical pathway development. 
 Conclusion: The infinity loop of design thinking can serve as an easy-to-use framework for quality improvement in healthcare. By transitioning from researcher-centered to user-centered design, the resulting clinical pathway can facilitate implementability and improve user satisfaction.

Strengthening the Diagnosis and Treatment of Malnutrition Through Increased Nurse Involvement: A Quality Improvement Project From Pediatric Wards in Mozambique.

Childhood acute malnutrition continues to be a serious health problem in many low-resource settings in Africa. On pediatric wards in Mozambique, missed opportunities for timely diagnosis and treatment of malnutrition may lead to poor health outcomes. To improve inpatient nutritional care, a quality improvement (QI) project was implemented that aimed to engage pediatric nurses in inpatient malnutrition diagnosis and treatment. In 2 Mozambican referral hospitals, for 6 months, the Plan-Do-Study-Act framework for QI was implemented to identify key drivers of the following measures: having complete anthropometric evaluation documented at admission, 3 or more weight measurements per hospitalization week, documentation of nutritional therapy for eligible patients, and documentation of referral for outpatient nutritional rehabilitation after discharge. Clinical data were abstracted from hospital charts and entered into an EpiInfo database, including a 3-month observation period after the project, and analyzed retrospectively. A total of 2,208 children from wards other than malnutrition were included in the analysis. Complete anthropometric evaluation at admission improved from 24.4% 2 months before the QI project to 80.1% during and 75.2% in the 3 months after the project (P<.001). The percentage of patients with 3 or more weight measurements per hospitalization week rose from 22.3% to 82.8% during and 75.0% after the project (P<.001). Documentation of nutritional therapy increased from 58.8% before to 67.1% during and 70.6% after the project (P=.54), and documentation of referral for outpatient nutritional rehabilitation after discharge decreased from 55.9% to 54.9% during and increased to 70.6% after the project, (P<.001). Nurse engagement may lead to important advancements in the diagnosis and treatment of acute malnutrition in pediatric wards other than malnutrition in Mozambique. Task-sharing, particularly nurse engagement, in combination with QI methodology, may be considered for wards in similar settings with a high burden of malnutrition.

REVISITING THE TEACHING NURSING HOME: PRAGMATIC EVALUATION IN A REAL-WORLD SETTING

Abstract Revisiting the Teaching Nursing Home (RTNH) is a renewal of the Teaching Nursing Home model pioneered in the 1980s, which found that creating partnerships between schools of nursing (SONs) and nursing homes (NHs) improved clinical outcomes. In its first two years, the RTNH initiative has fostered partnerships between three SONs and four NHs in Pennsylvania, and is planning to expand. The program is implementing the Institute for HealthCare Improvement Age-Friendly Health System “4Ms” quality improvement framework through an online learning network. The 4M quality improvement framework focuses on four evidence-based elements: Mobility, Mentation, Medication, and What Matters. In addition, the participating SONs are incorporating the 4Ms into curricula and clinical rotations. The evaluation will examine both implementation and outcomes for SONs and NHs. Measures include student competency, staff satisfaction and burnout, clinical process of care and resident outcomes. While some resident level measures can be extracted from the Minimum Data Set (MDS), others (deprescribing, rehabilitation goals, preference sensitive care) require access to the electronic medical record (EMR). The goal of this presentation is to describe the methodology for measuring the wide range of outcomes and to examine the performance of a synthetic comparison group to study overall quality using CASPAR data. We selected 1,764 similarly sized, non-profit NHs and conducted bivariate, and propensity score analysis to determine if the participating NHs were different on any observable characteristics. The findings suggest that the participating NHs were not statistically significantly different in terms of overall quality rating, staffing, or inspections.

Enhancing Quality of Congenital Heart Care Within Resource-Limited Settings.

Over 90% of the world's children with congenital heart disease (CHD) are born in the resources poor settings of low- to middle-income countries (LMICs). The shortfall in human and material resources and dysfunctional health systems leads to poor quality of care (QoC) which contributes substantially to suboptimal outcomes of patients with CHD in LMICs. Notwithstanding these challenges, it is possible to develop a quality improvement (QI) framework that can have a significant impact on outcomes and prevent a number of deaths. In this review, we examine the common barriers to implementing effective QI processes in LMICs. Using examples of successful QI initiatives in LMIC, we propose a broad framework that focuses on simple, yet effective measures involving cohesive efforts of all key participants guided and nurtured by a leadership that strongly values QoC.

Public-Private Partnership in Healthcare is a Necessity in Difficult Times: A case study

Healthcare delivery is a risky enterprise for both public and private systems which may face adversity in a volatile, uncertain, complex, and ambiguous world. There has been a global emergence of Public-Private Partnership (PPP) hospitals to enhance delivery of sustainable healthcare, although its existence in developing countries remains limited. Risk management strongly influences PPP success; few PPP hospitals were able to meet contractually specified quality and performance requirements, creating debate regarding merits of the PPP model. Conversely, we present a case study of the first PPP hospital operated by not-for-profit organisation in New South Wales, Australia, to successfully complete the contract period. A Continuous Quality and Performance Improvement Framework was applied at five stages of organisational growth during the contract term. This case study demonstrates adaptive leadership and just organisational culture are equally important in providing high quality healthcare services to the community. We show the future potential of PPP model for service delivery as a third option to pure public or private sector hospitals, even in the post COVID-19 era when there is likelihood of financial instability in many settings.

Using the UK standards for public involvement to evaluate the public involvement sections of annual reports from NIHR managed research centres

BackgroundWithin the United Kingdom (UK), the National Institute for Health and Care Research is the largest funder of health and social care research, and additionally funds research centres that support the development and delivery of research. Each year, award-holders of these research centres are required to write a report about their activities, including a summary of Patient and Public Involvement and Engagement (PPIE) activities. This study aimed to evaluate the PPIE sections of annual reports to identify best practice and challenges; this could inform future delivery of PPIE activities.MethodsA framework documentary analysis informed by the six UK Standards for Public Involvement (‘Inclusive opportunities’, ‘Working together’, ‘Support and learning’, ‘Communications’, ‘Impact’ and ‘Governance’) was conducted on 112 reports. A quality improvement framework (‘Insights’) was used to evaluate quality as one of: ‘Welcoming’, ‘Listening’, ‘Learning’ and ‘Leading’. Recommendations from this review were co-developed with stakeholders and public contributors.ResultsReports documented varying levels of quality in PPIE activities which spanned across all six UK Standards. Award-holders either intended to, or were actively working towards, increasing access and inclusivity of public involvement opportunities. Methods of working with public contributors were varied, including virtual and in-person meetings. Most award-holders offered PPIE support and learning opportunities for both public contributors and staff. Some award-holders invited public contributors to co-produce communication plans relating to study materials and research findings. The impact of public involvement was described in terms of benefits to public contributors themselves, and on an organisation and project level. Many award-holders reported inviting public contributors to share decision-making within and about governance structures.ConclusionsThis evaluation identified that most annual reports contained evidence of good quality PPIE practice with learning from public contributors. Using the UK Standards and Insights framework enabled exploration of the breadth and quality of PPIE activities. Recommendations include the need for a platform for centres to access and share PPIE best practice and for centres to collaborate with local and national partners to build relationships with the public through inclusive community engagement.

Patient satisfaction with community pharmacy COVID-19 vaccination in Northern Ireland

Abstract Introduction Northern Ireland’s community pharmacies have contributed substantially to the COVID-19 response, with over 436,000 COVID-19 vaccines administered since March 2021. Community pharmacy has an established role across the UK in delivering influenza vaccination programmes. Research has found that community pharmacy vaccination can increase vaccine availability and uptake and is highly valued by patients1, and although European studies have demonstrated high satisfaction with community pharmacy COVID-19 vaccination services2, further studies are required that are applicable to a UK context. Aim This evaluation aimed to measure user satisfaction with the HSC community pharmacy COVID-19 vaccination service, reasons why users chose community pharmacy for vaccination, and user attitudes towards service quality in three key quality domains of patient-centredness, professionalism, and privacy. The findings aimed to inform recommendations for service improvement for future vaccination campaigns. Methods Following ethical approval from Keele University School of Pharmacy &amp; Bioengineering Research Ethics Committee, a cross-sectoral survey of individuals accessing COVID-19 vaccination from 61 participating community pharmacies was carried out between 20th September 2022 and 3rd December 2022. Voluntary participation was offered to all individuals accessing COVID-19 vaccination from pharmacies purposively chosen as representative of the community pharmacy network. Respondent views on service quality and overall satisfaction were collected anonymously via a Microsoft Forms questionnaire. The results were analysed for overall satisfaction and across three quality domains of patient-centredness, professionalism and privacy identified from the literature as mattering most to users of pharmacy services3. The results were reported using descriptive statistics including frequencies, percentages, skewness and measurements of central tendency. The findings informed the development of five key recommendations for future service improvement. Results 135 patients completed the online questionnaire. Overall patient satisfaction was extremely high, with 100% of respondents indicating they would recommend the service to friends and family and that they would return to a community pharmacy for COVID-19 vaccination. 96% of participants cited convenience, trust, ease of access and time spent at the pharmacy as reasons they chose community pharmacy for vaccination. Respondents were very satisfied with the quality of the service provided across the domains of patient-centredness, professionalism and privacy. Over 95% of participants were very satisfied with the quality of the service, professionalism of the vaccinator and caring of the pharmacy team, however only 73.2% of respondents were very satisfied with the standard of the consultation room. Discussion/Conclusion Overall satisfaction with community pharmacy COVID-19 vaccination in Northern Ireland is very high. Participants largely chose to access vaccination from community pharmacies for reasons of convenience, trust, ease of appointment and time spent at the pharmacy. Users are very satisfied with service quality in terms of patient-centredness, professionalism and privacy. Although generalisation is limited due to relatively small sample size, underrepresentation of some geographical areas and the potential for selection bias arising from voluntary participation and use of online questionnaires, this evaluation still provides a framework for continued quality improvement and a detailed perspective on user attitudes towards community pharmacy COVID-19 vaccination that has informed the development of recommendations for service improvement.

Reducing Preventable Bleeding Visits and Institutional Factor Costs for Patients with Bleeding Disorders with a Prospective Quality Improvement Project

Providing optimal care to patients with bleeding disorders requires specialized physician, laboratory, pharmacy, nursing, and institutional resources best achieved at Hemophilia Treatment Centers (HTCs). Current systems for managing the care of a resource intensive patient population may be suboptimal. We observed frequent bleeding related hospitalizations and emergency room (ER) visits in patients with bleeding disorders treated at our HTC that could have been potentially prevented by changes in outpatient care delivery. We initiated a prospective quality improvement (QI) project to improve care delivery and to reduce preventable bleeding related hospitalizations and ER visits for adult patients treated at our HTC. The interventions targeted patient-level and systems-level factors contributing to preventable visits, and barriers to care in our patient population. We compared preventable bleeding related hospitalizations and ER visits, institutional factor cost, use of prophylaxis in severe hemophilia, primary care physician attainment, and patient electronic portal enrollment before and after the QI intervention. In our population of adult patients with bleeding disorders (N=88), the intervention significantly reduced the primary outcome of preventable bleeding hospitalization or ER visit (P=0.0082, Figure), and reduced such visits by 85.4%, meeting the pre-specified criteria for success. Institutional factor acquisition costs to treat preventable bleeding were reduced by 94.5%, from $11,800 to $640 per patient per year; a projected savings of $982,088 yearly. Use of factor prophylaxis in patients with severe hemophilia increased from 58.8% to 100%, attainment of a primary care physician increased from 69.4% to 86.4%, and use of the electronic patient portal increased from 53.2% to 83%; all secondary outcomes met pre-specified criteria of success and were statistically significant. HTC clinic visit attendance was low at 55.2%. The majority of patients (71.6%) had at least one outpatient urgent episode (mean 0.72 episode per year), and 93% had non-urgent management (mean 9.3 episodes per year) occurring outside of a clinic visit. These data demonstrate that concerted outpatient management of patients with bleeding disorders with a quality improvement framework can reduce preventable hospitalization and ER visits. Decreased inpatient utilization resulted in substantial reductions in factor costs at the health system level. The clinical effort required to achieve these results was substantial, and required frequent provider engagement outside of regular clinic visits. The HTC can improve patient outcomes and reduce institutional costs from preventable bleeding episodes by supporting a collaborative quality improvement process led by physician, nursing, and laboratory coagulation experts.

Implementing Tai Chi Exercise in Long-Term Care to Reduce Falls.

Falls are a frequent occurrence in older adults in long-term care facilities. At our long-term care facility, the percentage of patients who fell increased from 45% in 2021 to 68% in 2022, indicating a need for an evidence-based solution. We used an evidence-based quality improvement framework to pilot a tai chi exercise program. Residents were invited to participate in the Tai Ji Quan: Moving for Better Balance program for 12 weeks. Classes were 30 minutes long and included a 5-minute warm-up and 5-minute cooldown. Seventy-five residents participated in the tai chi program. There was a significant 32.3% reduction in falls (P =.001). Residents' fall risk scores decreased 14% (P < .001). Implementing a tai chi exercise project may affect falls and decrease the overall fall risk.

DELIVERING SUSTAINABLE CHANGE OF POSTOPERATIVE CARE DOCUMENTATION PRACTICES IN SPINAL SURGERY THROUGH QUALITY IMPROVEMENT FRAMEWORKS

AbstractINTRODUCTIONIn the NHS the structure of a “regular healthcare team” is no longer the case. The NHS is facing a workforce crisis where cross-covering of ward-based health professionals is at an all-time high, this includes nurses, doctors, therapists, pharmacists and clerks. Comprehensive post-operative care documentation is essential to maintain patient safety, reduce information clarification requests, delays in rehabilitation, treatment, and investigations. The value of complete surgical registry data is emerging, and in the UK this has recently become mandated, but the completeness of post-operative care documentation is not held to the same importance, and at present there is no published standard. This project summarises a 4-stage approach, including 6 audit cycles, &gt;400 reviewed operation notes, over a 5 year period.OBJECTIVETo deliver a sustainable change in post operative care documentation practices through quality improvement frameworks.METHODSStage 1: Characterise the problem and increase engagement through: SMART aims, process mapping, hybrid action-effect and driver diagram and stakeholder analysis. Multi disciplinary stakeholders were involved in achieving a consensus of evidence-based auditable criteria. Stage 2: Baseline audit to assess current practice. Stage 3: Intervention planning by stakeholders. Stage 4: Longitudinal monitoring through run charts and iterative refinement.RESULTSStage 1: Process mapping identified numerous downstream effects of the absence of critical information from operation notes, and the action-effect diagram highlighted the multiple unnecessary mitigating actions performed by ward staff. An MDT consensus was achieved on 15 essential criteria for complete documentation, including important negative fields. Interest-influence matrix identified stakeholder groups with high influence but low interest who needed engagement to deliver change. Stage 2: Baseline audit demonstrated unexpectedly poor documentation: &gt;75% compliance in 4 criteria, and &lt;50% compliance in 10 criteria, which elevated the interest of key stakeholders. Stage 3: A post-operative care template based on the 15 criteria was embedded within the existing IT software. It allowed use of existing operative templates, with a non-overwriting suffix requiring only two mouse clicks. Stage 4: Re-audit at 3 and 12 months showed improved and sustained compliance. At 24 months compliance had declined. Questionnaire of template usage identified problems of criteria response options, and lack of awareness of template by newly appointed staff. Template update improved compliance over the next 6 months (&gt;75% compliance in 11 criteria). Finally, a further reaudit conducted 12 months after the template update (5 years post baseline audit) showed a sustained improvement in compliance (&gt;75% compliance in 13 criteria).CONCLUSIONSSimple innovation through quality improvement frameworks has changed documentation practices by 1) achieving a consensus from stakeholders, 2) a “shock and awe” moment to highlight existing poor documentation and increase engagement 3) implementing change which fit easily into existing systems, 4) respecting autonomy rather than enforcing change and 5) longitudinal monitoring using run charts and an iterative process to ensure the template remains fit for purpose. This model has now successfully been translated to other subspecialities within the orthopaedic department.Declaration of Interest(b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.

Embedding a Quality Framework for medication safety standards in delirium and dementia: A Singapore Study in a geriatric psychiatry liaison service

Introduction Research on prescribing processes for psychotropic medication review in older adult patients with severe behavioural symptoms of delirium and dementia appears limited. We aimed to improve and achieve 100% clinical documentation of psychotropic medication reviews against defined medication safety standards in older adult patients in geriatric wards with delirium occurrence and dementia without delirium referred to the geriatric psychiatry liaison service. The secondary aim evaluated any reduction in psychotropic medications as defined by medication safety standards by comparing pre-and post-assessments. Methods A baseline measurement in April 2022 showed no documentation records of the study’s first three standards. PDSA methodology was employed to evaluate whether a medication review occurred following the creation and implementation of medication safety standards 1 to 4 in cycle one and adding the fifth standard in cycle 2. The first, second and third standards were medication reviews of all hypnotics, antipsychotics, and psychotropic polypharmacy. The fourth standard reviewed the anticholinergic burden scores measured by the Anticholinergic Effect on Cognition scale. The fifth standard reviewed blood pressure and postural hypotension monitoring. Results Using a quality improvement framework that embeds defined medication safety standards as an intervention, we have demonstrated good documentation records for a medication review to improve psychotropic prescribing processes in the older adult’s psychiatry liaison service in geriatric wards in all standards in the 2 study cycles. There was a reduction in all psychotropic medications at post-assessment as defined by the medication safety standards 1 to 4 in at least one cycle in delirium occurrence and dementia without delirium, except for zopiclone in delirium. Conclusions The study’s findings in a geriatric ward setting in a public hospital in Singapore support the feasibility of embedding medication review using defined medication safety standards to improve psychotropic medication prescribing processes in older adults with delirium occurrence and dementia without delirium.

Improving Massive Open Online Course Quality in Higher Education by Addressing Student Needs Using Quality Function Deployment

Massive Open Online Courses (MOOCs) are playing an increasingly important role in higher education. However, some MOOCs still suffer from low quality, which hinders the sustainable development of higher education. Course characteristics reflect students’ needs for online learning and have a significant impact on the quality of MOOCs. In the course improvement process, existing research has neither improved the MOOC quality from the perspective of student needs nor has it considered resource constraints. Therefore, to deal with this situation, we propose a student-needs-driven MOOC quality improvement framework. In this framework, we first map students’ differentiated needs for MOOCs into quality characteristics based on quality function deployment (QFD). Then, we formulate a mixed-integer linear programming model to produce MOOC quality improvement policies. The effectiveness of the proposed framework is verified by real-world data from China’s higher education MOOCs. We also investigate the impacts of budget, cost, and student needs on student satisfaction. Our results revealed that to significantly improve student satisfaction, the course budget needs to be increased by a small amount or the course cost needs to be greatly reduced. Our research provides an effective decision-making reference for MOOC educators to improve course quality.