Implementation Of Quality Improvement Program Research Articles

Barriers and enablers for externally and internally driven implementation processes in healthcare: a qualitative cross-case study

BackgroundQuality in healthcare is a subject in need of continuous attention. Quality improvement (QI) programmes with the purpose of increasing service quality are therefore of priority for healthcare leaders and governments. This study explores the implementation process of two different QI programmes, one externally driven implementation and one internally driven, in Norwegian nursing homes and home care services. The aim for the study was to identify enablers and barriers for externally and internally driven implementation processes in nursing homes and homecare services, and furthermore to explore if identified enablers and barriers are different or similar across the different implementation processes.MethodsThis study is based on an exploratory qualitative methodology. The empirical data was collected through the ‘Improving Quality and Safety in Primary Care – Implementing a Leadership Intervention in Nursing Homes and Homecare’ (SAFE-LEAD) project. The SAFE-LEAD project is a multiple case study of two different QI programmes in primary care in Norway. A large externally driven implementation process was supplemented with a tracer project involving an internally driven implementation process to identify differences and similarities. The empirical data was inductively analysed in accordance with grounded theory.ResultsEnablers for both external and internal implementation processes were found to be technology and tools, dedication, and ownership. Other more implementation process specific enablers entailed continuous learning, simulation training, knowledge sharing, perceived relevance, dedication, ownership, technology and tools, a systematic approach and coordination. Only workload was identified as coincident barriers across both externally and internally implementation processes. Implementation process specific barriers included turnover, coping with given responsibilities, staff variety, challenges in coordination, technology and tools, standardizations not aligned with work, extensive documentation, lack of knowledge sharing.ConclusionThis study provides understanding that some enablers and barriers are present in both externally and internally driven implementation processes, while other are more implementation process specific. Dedication, engagement, technology and tools are coinciding enablers which can be drawn upon in different implementation processes, while workload acted as the main barrier in both externally and internally driven implementation processes. This means that some enablers and barriers can be expected in implementation of QI programmes in nursing homes and home care services, while others require contextual understanding of their setting and work.

Common reasons for non-participation during the outcome measurement process: wheeled mobility service delivery quality improvement reporting

Objective The purpose of this paper is to describe non-participation during the outcome measurement step of the wheeled mobility service delivery process (WMSDP) based on the Functional Mobility Assessment (FMA)-Uniform Dataset (UDS) Registry. Introduction The WMSDP is a standard framework for the provision of wheeled mobility devices, and several factors influence the client’s experience throughout the process. Patient-reported outcomes are one way to measure the client’s experience as part of a quality improvement program. Methods A retrospective descriptive study was conducted on the FMA-UDS Registry to measure the response rate during the outcome measurement step of the WMSDP and describe the reasons an individual did not complete the FMA-UDS. The FMA-UDS was examined at two time points: pre-delivery and post-delivery of the wheeled mobility device. Results As of September 2, 2021, 10,253 cases have been entered into the FMA-UDS Registry. 2,247 cases were no longer participating pre-delivery, and an additional 3,905 cases were no longer participating post-delivery. The most common reasons for non-participation in the FMA-UDS pre-delivery and post-delivery included: equipment not delivered; provider no longer participating in the FMA-UDS; funding issues; no new equipment; client opted out; loss in contact; deceased; returned equipment; and other. Discussion The type and frequency of non-participation in the outcome measurement step of the WMSDP is critical to understanding why individuals participate in outcome measures and provides insight into the barriers and facilitators for the implementation of quality improvement programs.

Top five considerations for improving outcomes in black patients with heart failure: A guide for primary care clinicians

Black patients develop heart failure at younger ages and have worse outcomes such as higher mortality rates compared to other racial and ethnic groups in the United States. Despite significant recent improvements in heart failure medical therapy, these worse outcomes have persisted. Multiple reasons have been provided to explain the situation, including but not limited to higher baseline cluster of cardiovascular risk factors amongst Black patients, inadequate use of heart failure guideline directed medical therapy and delayed referral for advanced heart failure therapies and interventions. Strategic interventions considering social and structural determinants of health, addressing structural inequalities/ bias, implementation of quality improvement programs, early diagnosis and prevention are critically needed to bridge the racial/ ethnic disparities gap and improve longevity of Black patients with heart failure. In this review, we propose evidence-based solutions that provide a framework for the primary care physician addressing these challenges to engender equity in treatment allocation and improve outcomes for all patients with heart failure.

Implementation of a batched stepped wedge trial evaluating a quality improvement intervention for surgical teams to reduce anastomotic leak after right colectomy

BackgroundLarge-scale quality improvement interventions demand robust trial designs with flexibility for delivery in different contexts, particularly during a pandemic. We describe innovative features of a batched stepped wedge trial, ESCP sAfe Anastomosis proGramme in CoLorectal SurgEry (EAGLE), intended to reduce anastomotic leak following right colectomy, and reflect on lessons learned about the implementation of quality improvement programmes on an international scale.MethodsSurgical units were recruited and randomised in batches to receive a hospital-level education intervention designed to reduce anastomotic leak, either before, during, or following data collection. All consecutive patients undergoing right colectomy were included. Online learning, patient risk stratification and an in-theatre checklist constituted the intervention. The study was powered to detect an absolute risk reduction of anastomotic leak from 8.1 to 5.6%. Statistical efficiency was optimised using an incomplete stepped wedge trial design and study batches analysed separately then meta-analysed to calculate the intervention effect. An established collaborative group helped nurture strong working relationships between units/countries and a prospectively designed process evaluation will enable evaluation of both the intervention and its implementation.ResultsThe batched trial design allowed sequential entry of clusters, targeted research training and proved to be robust to pandemic interruptions. Staggered start times in the incomplete stepped wedge design with long lead-in times can reduce motivation and engagement and require careful administration.ConclusionEAGLE’s robust but flexible study design allowed completion of the study across globally distributed geographical locations in spite of the pandemic. The primary outcome analysed in conjunction with the process evaluation will ensure a rich understanding of the intervention and the effects of the study design.Trial registrationNational Institute of Health Research Clinical Research Network portfolio IRAS ID: 272,250. Health Research Authority approval 18 October 2019. ClinicalTrials.gov, identifier NCT04270721, protocol ID RG_19196.

Blood Pressure Control Among Black and White Adults Following a Quality Improvement Program in a Large Integrated Health System

A higher percentage of non-Hispanic Black (hereinafter, Black) adults vs non-Hispanic White (hereinafter, White) adults with hypertension have uncontrolled blood pressure (BP) contributing to racial and ethnic disparities in cardiovascular disease. In 2010, Kaiser Permanente Southern California began implementing quality improvement (QI) strategies aimed at reducing this disparity. To examine the change in BP control between Black and White patients before and after the implementation of a QI program. A QI quasi-experimental, difference-in-difference analysis was conducted of Kaiser Permanente Southern California patients 18 years or older included in the population care management hypertension registry. The study was conducted from December 31, 2008, to December 31, 2019. Data analysis was performed from November 20, 2020, to November 7, 2022. Quality improvement program implementation began in 2010. Blood pressure control (systolic BP <140 mm Hg and diastolic BP <90 mm Hg) was assessed using the last outpatient BP measurement in each calendar year. Changes in BP control between Black and White patients from before (2008-2009) to after (2016-2019) implementation of the QI program were examined using a difference-in-difference analysis. Blood pressure control disparities from 2008 through 2019 by age, sex, race and ethnicity, and factors associated with BP control were examined. The number of patients with hypertension increased from 624 094 in 2008 (mean [SD] age, 61.8 [13.5] years; 330 551 [53.0%] female patients; 89 407 [14.3%] Black and 284 116 [45.5%] White patients) to 855 257 in 2019 (mean [SD] age, 64.5 [13.6] years; 444 422 [52.0%] female patients; 107 054 [12.5%] Black and 331 932 [38.8%] White patients). Blood pressure control increased an absolute 4.6% (95% CI, 4.3%-4.8%) among Black patients and 2.1% (95% CI, 2.0%-2.2%) among White patients from before to after the QI program implementation (difference-in-difference: 2.5%; 95% CI, 2.2%-2.8%). The largest reduction in BP control disparity between Black and White female patients was for those aged 50 to 64 years (difference-in-difference: 3.8%; 95% CI, 3.2%-4.4%) and for those aged 18 to 49 years between Black and White male patients (difference-in-difference: 4.2%; 95% CI, 3.0%-5.5%). The proportion of BP control among Black male patients aged 18 to 49 years was the lowest throughout 2008-2019 compared with male and female patients in other age and racial and ethnic groups. In 2019, uncontrolled BP was more common among Black vs White patients (prevalence ratio: 1.13; 95% CI, 1.12-1.14). This QI program noted that disparities in BP control between Black and White patients were decreased but not eliminated following implementation of QI strategies aimed at reducing disparities in BP control. These findings suggest that more focused interventions may be needed to increase BP control among Black individuals.

The drivers and impediments of implementing the quality improvement programmes at a government hospital in Eswatini: The registered nurses' perspective

Implementation of quality improvement programmes in health care institutions is considered a priority for health institutions in improving the quality and safety of health care. The implementation of the programmes require efforts from all levels of staff and may be influenced by factors at an individual and organisational level. The purpose of this study was to describe and explore the drivers and impediments of the implementation of quality improvement programmes at a government hospital in Eswatini.A qualitative research design was used to explore and describe the drivers and impediments of implementing quality improvement programmes at a government hospital in Eswatini. Non-probability, purposive sampling was used to select the sample. Data were collected using face-to-face semi-structured interviews. Data analysis was conducted following Tesch’s method.The study identified human-related drivers as staff commitment and being appreciated and acknowledged. The organisational drivers were buy-in from management, capacity building, and a Multidisciplinary team approach, collaborations and partnerships. The human-related impediments were lack of ownership, resistance to change and lack of motivation. In contrast, organisational impediments were the absence of a clear implementation strategy, lack of leadership and management skills, lack of resources, poor reporting system and challenges from the government.Some significant drivers could be reinforced and challenges need to be addressed to facilitate the implementation of the programmes. Some of the human drivers and impediments were influenced by organisational drivers and impediments. Therefore, reinforcing organisational drivers and correcting impediments could be fundamental in enhancing the implementation of QIPs in the hospital.

Quality improvement program in Latin America decreases mortality after cardiac surgery: a before-after intervention study

BackgroundThe current challenge of cardiac surgery (CS) is to improve outcomes in adverse scenarios. The aim of this study was to assess the impact of a quality improvement program (QIP) on hospital mortality in the largest CS center in Latin America. MethodsPatients were divided into two groups: before (Jan 2013–Dec 2015, n = 3534) and after establishment of the QIP (Jan 2017–Dec 2019, n = 3544). The QIP consisted of the implementation of 10 central initiatives during 2016. The procedures evaluated were isolated coronary artery bypass grafting surgery (CABG), mitral valve surgery, aortic valve surgery, combined mitral and aortic valve surgery, and CABG associated with heart valve surgery. Propensity Score Matching (PSM) was used to adjust for inequality in patients’ preoperative characteristics before and after the implementation of QIP. A multivariate logistic regression model was built to predict hospital mortality and validated using discrimination and calibration metrics. ResultsThe PMS paired two groups using 5 variables, obtaining 858 patients operated before (non-QIP) and 858 patients operated after the implementation of the QIP. When comparing the QIP versus Non-QIP group, there was a shorter length of stay in all phases of hospitalization. In addition, the patients evolved with less anemia (P = 0.001), use of intra-aortic balloon pump (P = 0.003), atrial fibrillation (P = 0.001), acute kidney injury (P < 0.001), cardiogenic shock (P = 0.011), sepsis (P = 0.046), and hospital mortality (P = 0.001). In the multiple model, among the predictors of hospital mortality, the lack of QIP increased the chances of mortality by 2.09 times. ConclusionThe implementation of a first CS QIP in Latin America was associated with a reduction in length of hospital stay, complications and mortality after the cardiac surgeries analyzed.

Strategy of Financing Management to Improve the Quality of Islamic Education Institution

This study aimed to reveal the strategy of improving the quality of Islamic educational institutions through financing management at MIN 1 Banjarmasin. This study used a qualitative approach with a natural setting as the data source. The data were collected through observation, in-depth interviews, and document review. There were five respondents in this study, namely the head of the madrasa, the head of the curriculum, the treasurer, the school committee, and the new student admissions committee. The results of the were the education financing management strategy in improving the quality of teachers, which emphasizes professionalism and discipline, as well as task commitment to improving school quality. Educational financing management strategies in an effort to foster students are carried out through coaching in the arts, by sports, religion, scouts, English, and personality. The education financing management strategy in the field of facilities and infrastructure is carried out by increasing funding sources, implementing quality improvement programs to support facilities and infrastructure as well as teacher welfare. The conclusion of this study is that the implementation of madrasa finance at MIN 1 Banjarmasin has been going well and its performance needs to be maintained and improved. Financing at MIN 1 Banjarmasin has been managed professionally. Based on the results of the analysis of the quality of education, there is a positive and significant relationship with financing management, where with financing management madrasas are able to plan things that support quality improvement, for example, reliable financing will support the provision of infrastructure that supports learning, teacher self-development, and academic and non- academic achievement. student academics.

Overcoming Barriers to Radiation Oncology Access in Low-Resource Settings in the United States

Providing high-quality radiation therapy in medically underserved, low-resource environments can be challenging in the United States. During the American Society of Radiation Oncology 2020 Annual Meeting, the American Society for Radiation Oncology Committee on Health Equity, Diversity, and Inclusion hosted 4 radiation oncologists from both academic and community practices in an educational session. Speakers discussed creative ways to overcome barriers to equitable cancer care and outcomes for their vulnerable patient populations in both rural and urban settings. Successful tactics have included applying for state-sponsored grants, lobbying hospital leadership for equipment upgrades, implementing quality improvement programs specifically targeting the needs of the patient population, studying novel hypofractionation schedules, monitoring toxicities using wearable devices, and expanding transportation options.

Geographic variation in influenza vaccination among U.S. nursing home residents: A national study.

ObjectivesEstimates of influenza vaccine use are not available at the county level for U.S. nursing home (NH) residents but are critically necessary to guide the implementation of quality improvement programs aimed at increasing vaccination. Furthermore, estimates that account for differences in resident characteristics between counties are unavailable. We estimated risk‐standardized vaccination rates (RSVRs) among short‐ and long‐stay NH residents by U.S. county and identified drivers of geographic variation.MethodsWe conducted a retrospective cohort study utilizing 100% of 2013–2015 fee‐for‐service Medicare claims, Minimum Data Set assessments, Certification and Survey Provider Enhanced Reports, and Long‐Term Care: Facts on Care in the U.S. We separately evaluated short‐stay (<100 days) and long‐stay (≥100 days) residents aged 65 and older across the 2013–2014 and 2014–2015 influenza seasons. We estimated RSVRs via hierarchical logistic regression adjusting for 32 resident‐level covariates. We then used multivariable linear regression models to assess associations between county‐level NHs predictors and RSVRs.ResultsThe study cohort consisted of 2,817,217 residents in 14,658 NHs across 2798 counties. Short‐stay residents had lower RSVRs than long‐stay residents (2013–2014: median [interquartile range], 69.6% [62.8–74.5] vs 84.0% [80.8–86.4]), and there was wide variation within each population (range, 11.4–89.8 vs 49.1–92.6). Several modifiable facility‐level characteristics were associated with increased RSVRs, including higher registered nurse to total nurse ratio and higher total staffing for licensed practical nurses, speech‐language pathologists, and social workers. Characteristics associated with lower RSVRs included higher percentage of residents restrained, with a pressure ulcer, and NH‐level hospitalizations per resident‐year.ConclusionsSubstantial county‐level variation in influenza vaccine use exists among short‐ and long‐stay NH residents. Quality improvement interventions to improve vaccination rates can leverage these results to target NHs located in counties with lower risk‐standardized vaccine use.

Experiences and attitudes of registered nurses towards the implementation of quality improvement programmes at a government hospital in Eswatini

Quality improvement is becoming the cornerstone of effective and efficient delivery of quality healthcare services in recent times. Among other healthcare workers, nurses are the primary implementers of quality improvement programmes (QIPs). Their knowledge, understanding, attitudes and motivation determine the potential effects of the programmes. This study explored the experiences of registered nurses (RNs) towards the implementation of the QIP at a government hospital in Swaziland. The RNs’ attitudes toward the programme were also explored. Non-probability, purposive sampling was used to select the sample that comprised of eight RNs. Data were collected through in-depth, face-to-face interviews to explore and describe the RNs’ experiences and attitudes regarding the implementation of QIPs. A semi-structured interview guide was used to ask questions until data saturation was reached. Data analysis was conducted following Tesch’s method. Ethical considerations were adhered to. The results revealed both negative and positive experiences of the RNs towards QIPs. A negative attitude towards the programme developed due to the manner in which the programmes were introduced to the RNs and their perception of the programme as work overload. However, there was a positive outlook by the RNs towards the programme after they had undergone training on a QIP. The training improved their knowledge, job satisfaction and client outcome. They developed motivation, interest and commitment despite the challenges they encountered. The programme also enhanced the spirit of teamwork among the RNs and the support staff.

Artificial intelligence for non-polypoid colorectal neoplasms.

The miss rate of flat advanced colorectal neoplasia is still unacceptably high, especially in the Western setting, notwithstanding the widespread implementation of quality improvement programs and training. It is well known that flat morphology is associated with miss rate of colorectal neoplasia, and that this subset of lesions often shows a more aggressive biological behaviour. Artificial intelligence (AI) applied to the detection of colorectal neoplasia has been shown to increase adenoma detection rate, consistently across all lesion sizes and locations in the colon. However, there is still uncertainty whether AI can reduce the miss rate of flat advanced neoplasia, mainly because all published trials report a low number of flat colorectal lesions in their training sets, and this could reduce AI accuracy for this subset of lesions. In addition, flat lesions have different morphologies with variable prevalence and potentially different accuracy in their detection. For example, the subtle appearance and rarer frequency of a non-granular laterally spreading tumor (LST) could be much harder to identify than a granular mixed LST. In this review, we present a summary of the evidence on the role of AI in the identification of colorectal flat neoplasia, with a focus on data regarding presence of LSTs in the training/validation sets of the AI systems currently available on the market.

Global Trigger Tool methodology to detect adverse events: pilot study at Academic Hospital of Udine

Abstract Introduction Identification and measurement of adverse events (AEs) is crucial for patient safety in order to monitor them over time and to implement quality improvement programs, testing if they are effective. Global Trigger Tool (GTT) has been proposed as a low-cost method, being also the most effective to detect AEs. This study aims to describe the number of triggers, the rate and level of AEs identified by GTT and the most frequent type of AE. Methods The Italian version of the GTT was used. Ten paper-based clinical records (CRs) randomly selected every 2 weeks were reviewed from January to April 2019 by three independent reviewers (two nurses, one doctor) at the Academic Hospital of Udine. The AEs rates calculated are: AEs per 1,000 patient-days, AEs per 100 admissions, percentage of admissions with an AE. AEs were classified by harm levels according to National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). Results CRs reviewed were 80. Mean age of the patients was 69.3±16.4, women were 37.5%. Mean hospitalisation was 16.8±15.3. Nine were the cases of re-hospitalisation within 30 days (11.3%). The total number of trigger was 156. AEs were 31, with at least one AE on 27.5% of admissions, 38.8 AEs per 100 admissions and 23 AEs per 1,000 patient-days. AEs with harm level E, F and H were respectively 5 (16.1%), 24 (77.4%) and 2 (6.5%). The most frequent type of AE were hospital acquired infections with 15 cases (48.4%). Conclusions The most frequent type of AE was the hospital acquired infections. Rates and levels of AEs were higher than other international studies, probably because of the limited number of CRs reviewed. Key messages Global Trigger Tool is an effective method to detect adverse patient safety events in order to monitor them over time. The most frequent type of adverse events was the hospital acquired infections.

Kompetensi Kepala Sekolah Sebagai Leader Dalam Meningkatkan Pendidikan Mutu Pendidikan Agama Islam di Sekolah Dasar Al-Ma’arif 02 Singosari Malang

This study aims to describe, personality, understanding of vision and mission, decision-making systems, and communication of school principals as leaders in improving the quality of Islamic education in schools. This study uses a qualitative approach to the type of case studies, the analysis uses Milles and Huberman's analysis techniques. The result is an increase in the quality of Islamic Religious Education (PAI) very closely related to the competency capabilities of the principal as a leader. At SDI Al-Ma'arif 02 proves that the school principal is currently able to improve the quality of PAI because they have good leader competencies, namely, personalities based on Islamic values ​​competencies, decision-making abilities that satisfy all parties, understanding the development of vision, mission and strategic goals PAI learning and institutional as well as the implementation of quality improvement programs for PAI teachers. This competency can be seen from the ability of SDI Al-Ma'arif 02 to produce graduates who have high religious quality and establish synergy between institutions and the community.

Updates on pediatric sepsis.

Sepsis, defined as an infection with dysregulated host response leading to life‐threatening organ dysfunction, continues to carry a high potential for morbidity and mortality in children. The recognition of sepsis in children in the emergency department (ED) can be challenging, related to the high prevalence of common febrile infections, poor specificity of discriminating features, and the capacity of children to compensate until advanced stages of shock. Sepsis outcomes are strongly dependent on the timeliness of recognition and treatment, which has led to the successful implementation of quality improvement programs, increasing the reliability of sepsis treatment in many US institutions. We review clinical, laboratory, and technical modalities that can be incorporated into ED practice to facilitate the recognition, treatment, and reassessment of children with suspected sepsis. The 2020 updated pediatric sepsis guidelines are reviewed and framed in the context of ED interventions, including guidelines for antibiotic administration, fluid resuscitation, and the use of vasoactive agents. Despite a large body of literature on pediatric sepsis epidemiology in recent years, the evidence base for treatment and management components remains limited, implying an urgent need for large trials in this field. In conclusion, although the burden and impact of pediatric sepsis remains substantial, progress in our understanding of the disease and its management have led to revised guidelines and the available data emphasizes the importance of local quality improvement programs.

A Structured Quality Improvement Educational Curriculum Increases Surgical Resident Involvement in QI Processes

Patient safety and quality improvement (QI) processes are vitally important to healthcare systems. Training and experience in QI processes are mandated by the Accreditation Council for Graduate Medical Education (ACGME) for general surgery residents. The execution and efficacy of these training programs in residencies have thus far been inconsistent. The purpose of this study was to assess the effectiveness of our surgical residency's QI educational program. We instituted a formalized QI educational program for all residents in our academic general surgery residency program from 2018 to 2019. The curriculum included didactics, online educational resources, peer-group collaboration, and faculty mentorship. Residents performed a self-assessment survey of their knowledge, skill, and comfort levels with QI processes before and after the program using a 10-point Likert scale. The number of QI projects conducted, presented, and subsequently prepared for publication was enumerated. The ACGME resident survey program results regarding resident involvement in QI processes before and after program implementation were compared. After 1 year of the program, residents demonstrated significant increases in average self-assessed knowledge of QI processes (6.4 vs. 4.0, p < 0.05), knowledge of local QI resources (5.4 vs. 3.3, p < 0.05), and confidence in their ability to develop and implement a QI project (6.3 vs. 3.9, p < 0.05). The average number of QI projects each resident participated in the year preceding the program vs. during the program increased from 0.4 to 1.8 (p < 0.05). Ten of 26 residents (38%) reported no direct involvement in a QI project the preceding year before the QI program implementation, while 26/26 (100%) of residents reported direct involvement in at least 1 QI project during the implementation year. Residency program ACGME survey results regarding resident participation in QI increased from 86% (just below the national average of 87%) before the development of the QI program to 97% after program implementation. Implementation of a formalized, structured quality improvement education program for surgery residents significantly increased residents' participation in QI projects, as well as increasing their confidence in their knowledge and skillset to perform QI processes. The residency program's ACGME resident survey results regarding resident involvement in QI also improved during program implementation.

Evaluation of quality improvement intervention with nurse training in nursing homes: A systematic review.

Quality improvement may be a promising approach to improve the quality of care in nursing homes, and nurse training is a key step in a successful quality improvement practice. The implementation of training measures may be related to the quality of quality improvement practice. Little is known about the quality of quality improvement practice or effective nurse training measures that affect the quality of quality improvement interventions in nursing homes. The aim of this review was to assess the quality of available quality improvement intervention designs and present effective nurse training measures that contribute to a high-quality quality improvement intervention. We searched the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Embase and the Cochrane Library for articles published before March 2019. quality improvement intervention quality was evaluated using a standardised assessment tool. Descriptive synthesis was used for the analysis. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) Checklist was used for transparency. We included 12 articles, 1 was rated as perfect quality and 7 good quality. Out of these 8 studies, 3 features primarily reflected differences in quality: compliance, sustainability and replication ability of the interventions. They were affected by measures included provision of advanced training, available training resources, feedback process, building quality improvement teams, setting up mentors and nursing leadership training. Other recommended measures included external cooperation and leadership empowerment. A high-quality quality improvement intervention should consider how to improve compliance, sustainability and replication ability. Adapting measures that are compatible with nurse training may ensure a successful implementation of quality improvement programmes that are conducive to the effective improvement of service quality. Quality improvement programmes should take into account measures that are compatible with nursing staff training. These measures should help improve the quality of interventions and promote care service of nursing homes.

What are the characteristics of the champion that influence the implementation of quality improvement programs?

BackgroundQuality improvement in Healthcare is the new fashion actually. Rich countries and developing countries alike are trying to implement quality improvement initiatives to improve their performance and the quality of care. There is evidence in the scientific literature that the existence of a “champion” can play an important role in the successful implementation of quality improvement strategies. Most of the time, people get stuck at the implementation level: they know what to do but they fail to execute it in the organizational setting. That’s where a champion can be useful to facilitate the success of the change. There is a paucity of research on the link between the champion and the implementation of quality improvement programs. The aim of the study was to investigate the perceptions of stakeholders about the characteristics and qualities of the champion that could facilitate the successful implementation of quality improvement programs in health care settings in Haiti. MethodsTwenty semi-structured individual interviews and one small group discussion (n = 4) with providers, administrators, directors, and NGO representatives were conducted during a six months period. The total sample size was twenty-four (n = 24). The methods were informed by grounded theory and the data were analyzed using the constant comparative method and thematic content analysis approach. ResultsThe analysis resulted in eleven themes describing the characteristics and qualities of a successful champion: Communication and persuasion, proactivity, humility, horizontal and collective leadership style, sense of responsibility and accountability, go-ahead type, empathy, dedication and motivation, ability to inspire and motivate people, have a vision, and encourage learning. ConclusionsIt is important to support and encourage champions in the health care systems in developing countries to master and exhibit those qualities and characteristics in order to lead a team for the successful implementation of quality improvement initiatives in the health facilities. More research is needed to understand how to better articulate those qualities in the context of the Haitian health care system.

Abstract TP37: Ten-Year Single Center Experience of Intra-Hospital Triage for Endovascular Treatment: The Hardest Hurdle During Late Off-Duty Hours

Background and Purpose: Intra-hospital time delays can affect the outcome following endovascular treatment (EVT). To overcome these hurdles, multidisciplinary quality improvement (QI) program could be helpful in that it can improve intra-hospital time-related factors with subsequent better clinical outcome. We aimed to describe our ten-year experience of endovascular triage via the multidisciplinary QI program with emphasis on time-related factors. Methods: Based on our prospectively maintained EVT registry (n=602), three consecutive periods were defined based on the implementation of QI program and the changes in the primary modality of first angiographic imaging: (1) period 1 (May 2006 to December 2009); (2) period 2 (January 2010 to August 2012); and (3) period 3 (September 2012 to April 2016). Definitions of working hours: On-duty was defined as regular working hour from AM 8:00 to PM 6:00, and off-duty was defined as night shift from PM 6:00 to AM 8:00 the following day. Off-duty was classified into two groups by early off-duty as PM 6:00 to midnight and late off-duty as midnight to AM 08:00 the next day. Also, regular working hours in holidays were considered same as early off-duty. Results: Overall, successful reperfusion (mTICI 2b-3, post-procedure) and favorable outcome (mRS 0-2 or equal to pre-stroke mRS, at 3-month) was achieved in 395 patients (65.6%) and 311 patients (51.6%), respectively. A trend for increase in successful reperfusion and favorable outcome over periods was observed ( p&lt;0.001 , respectively). Also, significant trends for shorter door-to-picture and door-to-puncture (DtoP) times over periods were observed ( p&lt;0.001 , respectively). Inside each period, late off-duty hours were the hardest time period for improvement. In period 3, the DtoP time was 98.0 (IQR 79.0 - 118.0) minutes in late off-duty hours compared to 77.0 (IQR 60.5 - 88.5) minutes in on-duty hours ( p&lt;0.001 ). Conclusions: Upward trend in successful reperfusion and better outcome were observed along with improvement in intra-hospital workflow to decrease door-to-puncture time, which emphasizes the importance of incessant QI program of EVT workflow. However, late-off duty hours were the hardest time point for improvement.

Abstract TP394: Inpatient Onset Stroke Protocols in the Era of Value Based Medicine: Can We Remove Effectively Process Inefficiencies?

Introduction: The American Stroke Association guidelines (2018) extension of the window for stroke interventions created an opportunity for quality improvement (QI) efforts in a sub-population designated as In-hospital (Inpatient) strokes (IHS). The new focus on salvageable tissue allows qualified IHS to receive effective reperfusion interventions. To improve outcomes in this population, hospitals are designing protocols and QI initiatives specific to IHS. Methods: An analysis of the implementation of a Code Stroke Rapid Response Team (RRT) process in a Primary (PSC) and a Comprehensive Stroke Center (CSC) was performed. We utilized descriptive statistics and cost estimation of centralizing the care of IHS on dedicated units. Results: CSC patients had a lower treatment -OR=0.17 CI 95%, and a higher mimics rate -OR= 3.03 95% CI compared to PSC. Cost of intra-hospital transfers was estimated at $5,000 to $8,000. Most of IHS occurred in cardiothoracic and trauma patients. While overall quality metrics improved -symptom discovery to CT 47% under 25 min, discovery to assessment 90% under 10 min, in the CSC the intra-hospital transfers contributed to added expenditures. The false-positive calls documented multiple contraindications to acute interventions. Conclusions: When implementing QI programs, hospitals should balance available resources, patients population specifics, and desired outcomes. Creating one-size-fits-all protocols can lead to multiple wastes in complex organizations. In the era of Value-Based Medicine and declining reimbursements, adopting flexible organization-specific and clinically oriented pathways and aligning treatment goals of multi-specialty teams will address the needs of IHS. Utilization of tools specific to early detection of IHS and further studies with a systematic collection, evaluation, and analysis of data is needed. Fostering efficient and consistent team communication and processes that balance quality metrics and fiscal responsibilities based on hospital structural and functional differences should become the next step in designing Code Stroke protocols. Real-World Evidence from sharing results will lead to an improvement in inpatient stroke care and patients’ outcomes- a mission long overdue.